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VERTICAL  ANTERO-POSTERIOR  SECTION-  OF  THE 
NASAL    CAVITIES,  MOUTH,  PHARYNX  AND  LARYNX. 


C.R  Sajous,  Pin  Kit. 


W.H. BUTLER  Ao?  LITH.  PHI  LA 


LECTURES 


ON   THK 


DISEASES 


NOSE  AND  THROAT, 

DELIVERED   DURING    THE  SPRIXG  SESSION  OF 
JEFFERSON  MEDICAL   COLLEGE. 


CHARLES   E.   SAJOUS,  M.D., 

Lecturer  on   Khinology  and  Laryngology  in  the  Spring  Course  of  Jefferson  Medical  College;    one  of  the 

physicians  in  charge  of  the  Throat  Department,  Jefferson  College  Hospital;   Ex-President  of  the 

Philadelphia   Laryngologic.il  Society;    Fellow  of  the    American    Laryngological 

Association  ;  Corresponding  Member  of  the  Royal  Society  of  Belgium 

and  of  the  Medical  Society  of  Warsaw  (Poland),  etc.,  etc. 


ILLUSTRATED  \vrrn  ONE  HUNDRED  CHROMO-LITHOGRAPHS,  FROM  OIL  PAINTINGS 
THE  AUTHOR,  AND  NINETY-THREE  ENGRAVINGS  ON  WOOD. 


PHILADELPHIA  : 

F.   A.    DAVIS,  ATT'Y,   PUBLISHER 
No.  1217  FILBERT  STREET. 
1885. 


Entered  according  to  Act  of  Congress,  in  the  year  1885,  by 

F.  A.  DAVIS,  ATT'Y, 

In  the  Office  of  the  librarian  of  Congress  at  Washington. 
All  rights  reserved. 


TO  THE  MEMORY  OF 

PROF.  SAMUEL  D.  GROSS,  M.D.,  LL.D. 

(D.G.L.  Oxon.;   LL.D.  Cantab.;   LL.D.  Edin.; 
LL.D.  Univ.  Penna.) 

THIS  WORK  IS .  AFFECTIONATELY 

DEDICATED 

BY 
THE    AUTHOR. 


246515 


PREFACE. 


IN  presenting  this  work  to  the  profession,  the  author's 
object  is  to  furnish  the  general  practitioner  not  only  a 
guide  for  the  treatment  of  the  diseases  of  the  nose  and 
throat,  but  also  to  place  before  him  a  representation  of 
the  normal  and  diseased  parts  as  they  would  appear  to 
him  were  they  seen  in  the  living  subject.  To  do  jus- 
tice to  such  an  undertaking,  coloring  was  obviously  of 
prime  importance,  the  difference  between  the  normal  and 
pathological  state  frequently  being  only  appreciable  in 
the  change  of  color.  With  this  object  in  view,  the  author 
has  performed  the  part  of  artist,  as  well  as  anatomist, 
believing  that,  though  deficient  in  the  former  capacity,  he 
might  be  able  to  furnish  more  accurate  representations 
than  if  the  task  were  confided  to  a  capable  artist,  un- 
familiar with  the  special  subject.  Ninety-seven  out  of 
the  hundred  illustrations  are  original,  the  great  majority 
of  the  cases  presented  being  taken  from  the  author's 
private  and  hospital  practice.  Most  of  the  anatomical 
plates,  notably  those  on  the  larynx,  were  copied  from 
nature,  the  rest  being  compiled  from  text-books  on  anat- 
omy. Some  illustrations,  as  may  be  noticed,  are  somewhat 
diagramatic,  the  intention  being  to  render  them  easier  of 
comprehension.  As  regards  the  lateral  sections  repre- 

(v) 


VI  PREFACE. 

senting  active  disease  in  the  nasal  cavities,  they  are 
based  upon  careful  anterior  and  posterior  rhinoscopic 
examinations.  Each  colored  plate  has  before  it  an  explana- 
tory page,  with  the  exception  of  Plate  I,  which,  in  addition 
to  the  description  given  beneath  it,  represents  the  location 
of  the  hyperaBsthetic  spots  in  a  case  of  hay  fever  treated  by 
the  author. 

The  plain,  concise,  though  explanatory  language  em- 
ployed in  lecturing  before  students,  has  been  preserved ; 
technical  terms  have,  as  much  as  possible,  been  avoided, 
and,  when  employed,  their  meaning  is  made  obvious  by 
the  general  sense  of  the  phrase  containing  them.  Dis- 
cussions have  not  been  entered  into,  the  theories,  as  to 
etiology  and  pathology,  given,  representing  those  most 
generally  accepted,  with  what  suggestions  the  observa- 
tions of  the  author  have  rendered  warrantable.  An  ex- 
ception to  this  rule  has  been  made,  however,  in  the 
case  of  hay  fever,  in  order  to  better  illustrate  the  recent 
views  as  to  the  etiology  and  treatment  of  that  disease. 

In  relation  to  treatment,  the  facilities  furnished  the 
author  by  one  of  the  finest  clinics  of  the  United  States 
and  a  rather  extensive  practice,  have  enabled  him  to 
test  the  therapeutical  value  of  the  majority  of  new 
methods  that  have  come  under  his  notice.  Only  those 
presenting  advantages  over  older  modes  of  treatment  have 
been  mentioned,  those  recommended  having  been  pro- 
ductive of  the  best  results.  The  instruments,  with  very 
few  exceptions,  represent  the  author's  armamentarium. 

The    classification    of    diseases    varies     somewhat    from 


PREFACE.  Vli 

that  of  other  works  on  the  subject.  The  affections  have 
been  classed  in  rotation,  according  to  the  progressive  patho- 
logical changes  peculiar  to  them.  Diseases  in  which  throat 
affections  merely  occur  as  a  symptom — such  as  diphtheria, 
scarlatina,  etc. — have  been  omitted,  not  belonging  strictly 
to  maladies  of  the  throat. 

In  two  cases,  the  author  has  taken  the  liberty  to  suggest 
new  terms :  "  Periodical  Hypera3sthetic  Ehinitis,"  which 
appears  to  him  as  suggesting  not  only  the  true  pathological 
process  of  the  so-called  "hay  fever,"  but  also  its  rational 
treatment ;  and  "  Posterior  Nasal  Pharyngitis,"  a  term 
better  suited  than  "Post-nasal  Catarrh"  to  indicate  the  true 
location  of  that  affection,  its  anatomical  character  and  its 
pathological  basis. 

In  the  preparation  of  the  work  the  author  has  availed 
himself  of  the  several  excellent  works  on  the  diseases  of 
the  nose  and  throat  published  within  the  last  few  years, 
principal  among  which  may  be  mentioned  those  by  Morell 
Mackenzie,  of  London;  J.  Solis  Cohen,  of  Philadelphia;  F. 
H.  Bosworth,  of  New  York;  Edward  Woakes,  of  London; 
C.  Fauvel,  of  Paris;  E.  Zuckerkandl,  of  Vienna;  Gr.  M.  Lef- 
ferts,  of  New  York;  Lennox  Browne,  of  London,  and 
Clinton  Wagner,  of  New  York.  Among  the  works  on 
pathology  that  have  been  consulted,  Cornil  and  Banvier, 
Green,  Frey,  and  Heitzmann  are  the  principal.  The  char- 
acter of  the  work  preventing  copious  reference,  the  author 
desires  to  state  that  of  the  two  hundred  and  odd  papers 
perused,  he  has  received  the  most  valuable  information 
from  the  contributions  to  the  literature  of  the  subject 


Vlll  PKEFACE. 

by  Felix  Semon,  of  London ;  Gordon  Holmes,  of  Lon- 
don; David  Newman,  of  Glasgow;  W.  MacNeill  Whistler, 
of  London ;  Th.  Hering,  of  Warsaw ;  L.  Bayer,  of  Brus- 
sels ;  E.  J.  Moure,  of  Bordeaux ;  O.  Cliiari,  of  Vienna ; 
Ph.  Schech,  of  Munich ;  G.  Poyet,  of  Paris,  and  other 
equally  eminent  foreign  writers,  while  among  American 
productions  may  be  mentioned  those  of  Harrison  Allen, 
of  Philadelphia;  G.  M.  Lefferts,  of  New  York;  R.  P. 
Lincoln,  of  New  York;  F.  I.  Knight,  of  Boston;  T.  A. 
DeBlois,  of  Boston;  8.  W.  Langmaid,  of  Boston;  George 
W.  Major,  of  Montreal;  Clinton  Me  Sherry,  of  Baltimore; 
Hiram  Christopher,  of  St.  Joseph;  T.  H.  Hartman,  of  Balti- 
more, and  the  authors  whose  names  appear  in  the  text. 

The  author  wishes  to  state  that  he  is  under  many  obli- 
gations to  his  clinical  assistant,  Dr.  C.  Sunnier  Witherstine, 
of  Germantown,  for  valuable  assistance  in  the  preparation 
of  the  work;  and  to  Mr.  F.  A.  Davis,  his  publisher,  who 
has  spared  nothing  to  render  the  work  worthy  of  its 
readers. 

The  colored  plates  have  been  prepared  by  Mr.  W.  H. 
Butler,  of  Philadelphia,  while  the  wood-cuts  were  engraved 
by  Messrs.  Fickinger  &  Stowell,  of  Philadelphia,  who,  in 
excellence  of  workmanship  and  promptness  are  not  sur- 
passed. 

1630  CHESTNUT  STREET, 
PHILADELPHIA. 


TABLE  OF  CONTENTS. 


CHAPTER   I. 
ILLUMINATION  1 


PAG!- 


CHAPTER  II. 
ANATOMY  AXD  PHYSIOLOGY  OF  THE  NASAL  CAVITIES.        .      12 

Anatomy  xot'  the  Anterior  Nasal  Cavities — Anatomy  of  the 
Posterior  Nasal  Cavity — Physiology  of  the  Nasal  Cavi- 
ties. 

CHAPTER   III. 
RHINOSCOPY 22 

Anterior  Rhinoscopy — Posterior  Rhinoscopy. 

CHAPTER  IV. 

INSTRUMENTS  USED  IN  CLEANSING  AND  MEDICATING  THE 

NASAL  CAVITIES 3«> 

CHAPTER  V. 

THERAPEUTICS  OF  THE  NASAL  CAVITIES      ....      52 

CHAPTER  VI. 

DISEASES  OF  THE  ANTERIOR  NASAL  CAVITIES  (i4 

Acute  Rhinitis — Simple  Chronic  Rhinitis — Hypertrophic 
Rhinitis — A  trophic  Rhinitis. 

CHAPTER  VII. 
DISEASES  OF  THE  ANTERIOR  NASAL  CAVITIES— (Con tinned]    122 

Svphilitic  Rhinitis— Scrofulous  Rhinitis. 

(ix) 


X  CONTENTS. 

CHAPTER  VIII. 

PAGE 

DISEASES  OF  THE  ANTERIOR  NASAL  CAVITIES — (Continued)    136 

Tumors:  Myxoina,  or  Mucous  Polypus — Fibroma,  or 
Fibrous  Polypus — Papilloma — C3'st — Ecchondroma — 
Osteoma — Exostosis — Sarcoma — Carcinoma. 

CHAPTER   IX. 

DISEASES  OF  THE  ANTERIOR  NASAL  CAVITIES — (Continued)     160 

Diseases  of  the  Septum :  Deviation  of  the  Septum — Hamia- 
toma  of  the  Septum — Abscess  of  the  Septum — Sub- 
mucous  Infiltration  of  the  Septum. 

CHAPTER   X. 

DISEASES  OF  THE  ANTERIOR  NASAL  CAVITIES — (Continued)    170 
Neuroses  :  Periodical  HyperiEsthetie  Rhinitis — Anosmia. 

CHAPTER  XI. 

DISEASES  OF  THE  ANTERIOR  NASAL  CAVITIES — (Continued)    206 

Epistaxis — Foreign  Bodies  in  the  Nasal  Passages — Rhino- 
liths — Maggots  in  the  Nose. 

CHAPTER  XII. 

DISEASES  OF  THE  POSTERIOR  NASAL  CAVITY       .        .        .    216 

Acute  Posterior  Nasal  Pharyngitis — Chronic  Posterior. 
Nasal  Pharyngitis — Hypertrophic  Posterior  Nasal 
Pharyngitis — Naso-Pharyngeal  Polypus. 

CHAPTER  XIII. 

ANATOMY  AND  PHYSIOLOGY  OF  THE  PHARYNX    .        .        .    239 
The  Pharynx— The  Soft  Palate— The  Tonsils. 

CHAPTER  XIV. 
PHARYNGOSCOPY  242 


CONTENTS.  XI 

CHAPTER  XV. 

PAGE 

INSTRUMENTS  USED  IN  CLEANSING  AND  MEDICATING  THE 

PHARYNX 244 

CHAPTER   XVI. 
THERAPEUTICS  OF  THE  PHARYNX 248 

CHAPTER  XVII. 
DISEASES  OF  THE  PHARYNX 250 

Acute  Pharyngitis — Simple  Chronic  Pharyngitis — Follicu- 
lous  Pharyngitis — Membranous  Pharyngitis — Atrophic 
Pharyngitis. 

CHAPTER  XVIII. 
DISEASES  OF  THE  PHARYNX — (Continued)    ....    266 

Tuberculous  Pharyngitis — Syphilitic  Pharyngitis. 

CHAPTER  XIX. 

DISEASES  OF  THE  PHARYNX — (Continued)    .  .        .    272 

Retro-Pharyngeal  Abscess — Tumors  of  the  Pharynx — Para- 
Lysis  of  the  Pharynx — Foi'eign  Bodies  in  the  Pharynx. 

CHAPTER  XX. 
DISEASES  OF  THE  TONSILS  AND  UVULA       ....    281 

Tonsillitis — Hypertrophy  of  the  Tonsils — Relaxation  of  the 
Soft  Palate  and  Uvula. 

CHAPTER  XXI. 
ANATOMY  AND  PHYSIOLOGY  OF  THE  LARYNX       .        .        .300 

CHAPTER   XXII. 
LARYNGOSCOPY 310 

Obstacles  to  Laryngoscopy. 


Xll  CONTENTS. 

CHAPTER  XXIII. 

PAGE 

INSTRUMENTS  USED  IN  CLEANSING  AND  MEDICATING  THE 

LARYNX   .  318 

CHAPTER  XXIV. 

THEEAPEUTICS  OF  THE  LARYNX    .  , 32-i 

CHAPTER  XXV. 
DISEASES  OF  THE  LARYNX 327 

Sub-acute    Laryngitis — Acute     Laryngitis — (Edema    of    the 
Larynx — Chronic  Laryngitis. 

CHAPTER   XXVI. 

DISEASES  OF  THE  LARYNX — (Continued)      .  343 

Tuberculous  Laryngitis — Syphilitic  Laryngitis. 

CHAPTER  XX  VII.  • 
DISEASES  OF  THE  LARYNX — (Continued)      ....    357 

Neuroses:     Motor    Paralysis — Hysterical    Aphonia — Spasm 
of  the  Glottis. 

CHAPTER   XXVIII. 
DISEASES  OF  THE  LARYNX — (Continued)      ....    378 

Tumors  :    Non-Malignant    Tumors — Semi-Malignant  Tumors 
— Malignant  Tumors — Foreign  Bodies  in  the  Larynx. 

CHAPTER   XXIX. 

ARTIFICIAL  OPENINGS  INTO  THE  LARYNX  AND  TRACHEA    .    398 
Laryngotomy  —  Thyrotomv  —  Laryngo  Tracheotomy  —  Tra- 
cheotomy. 


LECTURES 

ox  THE 

DISEASES  OF  THE  NOSE  AND  THROAT, 


CHAPTER  I. 

ILLUMINATION. 

GAKCIA,  in  his  first  efforts  to  illuminate  the  larynx  in  1854, 
made  use  of  the  sun's  rays.  He  soon  found,  however,  that  they 
were  not  available  at  all  times,  not  only  on  account  of  the  con- 
stantly changing  relative  positions  of  the  sun  and  earth,  but 
also  through  the  irregularities  of  the  weather.  The  fogs  of 
London  adding  much  to  these  causes  of  interference,  he  was 
often  obliged  to  cease  his  observations  for  days  and  weeks  at  a 
time.  Not  finding  the  light  of  an  ordinary  lamp  sufficiently 
powerful,  he  tried  the  oxy-hydrogen  and  electric  lights;  but 
these,  being  as  yet  very  imperfect,  proved  unsatisfactory. 

A  few  years  later  Czermak,  of  Pesth,  to  whom  belongs  the 
honor  of  having  introduced  laryngoscopy  and  rhinoscopy  in  the 
practice  of  medicine,  made  a  series  of  observations  upon  him- 
self, using  the  light  of  an  ordinary  student  lamp.  Since  then, 
artificial  light,  a  term  applied  to  all  lights  other  than  that  of 
the  sun — which  in  contradistinction  is  called  natural  light — 
has  been  in  universal  use. 

I  Natural  light,  however,  can  often  be  used  to  great  advantage, 
nothing  equalling  the  brilliancy  and  steadiness  of  the  sun's 
rays.  These  may  be  directed  into  the  mouth  of  the  patient,  or 
reflected  into  it  by  means  of  a  small  toilet  mirror,  either  held 
in  the  hand  or  so  mounted  that  it  can  be  tilted  in  any  direc- 
tion. Diffuse  daylight  may  also  be  used  in  the  same  manner. 


2 


ILLUMINATION. 


Direct  illumination  is  used  principally  on  the  Continent  of 
Europe,  by  directing  the  light,  with  or  without  a  condenser, 
into  the  cavity  to  be  examined.  This  is  not  to  be  recom- 
mended, because  the  apparatus  furnishing  the  light  has  to 
stand  between  the  observer  and  the  patient,  thus  interfering 
with  the  former's  movements. 

A  mirror  especially  adapted  for  the  purpose  of  reflecting  light 
from  whatever  source  it  may  be  obtained,  was  also  introduced 
by  Czermak,  and  is  now  in  general  use.  It  is  called  the  larynyo- 
scopic  reflector  (Fig.  1),  and  consists  of  a  round  concave  mirror, 


Reflector  with  circular  head-band. 


three  to  four  inches  in  diameter,  with  a  focus  of  from  eight  to 
fourteen  inches.  As  ordinarily  made,  it  has  a  focus  of  twelve 
inches,  and  can  be  used  by  the  majority  of  persons.  A  head- 
band is  attached  to  it,  by  means  of  a  ball-and-socket  joint, which 
enables  it  to  be  inclined  in  any  direction  when  in  position. 

A  much  more  convenient  head  attachment,  however,  is  that 
invented  by  Mr.  Ivan  Fox,  an  optician  of  Philadelphia.    It  con- 


EEFLECTOES. 


3 


sists  of  four  steel  blades,  three-quarters  of  an  inch  wide,  con- 
nected longitudinally  by  hinges,  and  forming  a  steel  band  which, 
when  opened,  assumes  the  shape  of  a  line  passing  over  the  head, 


Fig.  2. 


Reflector  with  Fox's  head-band. 

from  forehead  to  occiput  (Fig.  2).  One  end  is  attached  to 
the  ball-and-socket  joint  piece,  while  the  other  is  furnished 
with  a  short  transverse  blade,  which  serves  as  a  cushion  for 
the  occiput.  These  ends  are  five  inches  apart,  and,  the  fronto- 
occipital  diameter  being  much  more,  when  the  band  is  passed 
over  the  head,  it  grasps  it  firmly,  affording  solid  support  for 
the  mirror.  As  shown  in  Fig.  3,  the  hinges  are  placed  at 

Fig.  3- 


Fox's  head-band  folded  around  reflector. 


such  intervals  that  when  the  mirror  is  not  in  use  the  band 
can  be  wrapped  around  it,  thus  rendering  it  portable  while 
protecting  it  perfectly. 


4-  ILLUMINATION. 

Reflectors  are  generally  perforated  through  the  middle,  as  in 
Fig.  1.  The  hole  being  held  before  the  pupil  of  the  observer, 
enables  him  to  bring  his  line  of  vision  parallel  with  and  in  the 
center  of  that  of  the  reflected  light.  Some  laryngologists, 
however,  contend  that  the  perforation  is  not  only  unnecessary, 
but  that  it  should  not  be  used,  both  eyes  being  required  to 
obtain  a  correct  interpretation  of  distances.  They  consequently 
advise  wearing  the  mirror  on  the  forehead.  For  my  part,  I 
find  the  perforation  advantageous,  and  can  obtain  a  clearer 
image  with  than  without  it.  Besides,  the  mirror  forms  an 
excellent  shield  for  the  face — a  rather  important  matter,  espe- 
cially in  hospital  practice. 

Instead  of  being  attached  to  a  head-band,  the  mirror  is  some- 
times connected  with  the  apparatus  furnishing  the  light,  by 
means  of  a  slender  jointed  arm  (See  Fig.  4).  When  it  is  used 
frequently,  this  arrangement  is  not  only  much  more  convenient, 
but  the  reflected  light,  not  being  influenced  by  the  motions  of 
the  head,  is  maintained  absolutely  steady — a  marked  advantage, 
especially  in  operations. 

Of  artificial  lights,  gas  is  certainly  the  most  convenient,  being 
cleanly  and  always  ready.  An  ordinary  bracket  may  serve  the 
purpose,  but  the  light  it  furnishes  can  be  much  improved  by 
adding  an  Argand  burner,  which  will  give  a  round  instead  of  a 
flat  flame.  It  can  be  further  improved  by  causing  it  to  pass 
through  a  lens,  which  will  concentrate  its  rays.  The  apparatus 
I  use  in  the  clinic  is  that  constructed  by  Tobold,  of  Berlin, 
mounted  on  a  photographer's  head-stand,  as  devised  by  Cohen. 
Its  principal  feature  is  a  set  of  lenses  held  in  a  cylindrical  tube, 
by  means  of  which  the  rays  of  light  are  concentrated  and 
evenly  diffused.  The  parts  are  thus  illuminated  evenly,  and 
the  perpendicular  shadows  existing  in  a  light  directly  trans- 
mitted from  the  flame  are  avoided. 

Dr.  Morell  Mackenzie's  light  condenser  is  much  less  compli- 


ALBO-CAKBON   LIGHT.  5 

cated  and  quite  as  efficient.  It  consists  of  a  metallic  cylinder 
with  a  round  opening  in  its  side,  over  which  is  applied  a  plano- 
convex lens.  This  cylinder  is  passed  over  the  chimney  of  the 
Argand  burner  and  adjusted  so  as  to  bring  the  center  of  the 
lens  just  opposite  that  of  the  flame.  The  same  author  has  de- 
rig.  4. 


Mackenzie's  bull-eye  condenser  with  reflector  attached. 

vised  a  rack  movement  bracket  much  used  by  specialists.  Fig. 
4  represents  a  bracket  much  like  Dr.  Mackenzie's  but  the  rack 
is  replaced  by  a  sliding  ring  furnished  with  a  thumb-screw,  by 
means  of  which  the  instrument  can  be  steadied  if  necessary. 
Its  joints  are  sufficiently  tight,  however,  to  maintain  it  in  any 
position,  and  the  sliding  ring  is  only  accessory. 

I  have  been  using  of  late  a  new  method  lately  introduced  for 
general  purposes,  by  which  gas-light  is  made  much  brighter, 
whiter  and  steadier.  The  gas  is  caused  to  pass  through  a 
metallic  vessel  containing  a  specially  prepared  substance  called 
"albo-carbon"  which,  being  vaporized  by  the  heat  of  the  gas 
flame,  so  enriches  the  gas  as  to  raise  its  illuminating  power  to 
the  highest  degree.  The  metallic  vessel  or  generator  can  be 
readily  fitted  to  any  bracket.  Fig.  5  represents  the  instrument 
mounted  on  a  bracket  with  attachment  for  laryngoscopic  ex- 
aminations. 

The  attachment  consists  of  a  thin  sheet-iron  shield  five  inches 


6 


ILLUMINATION. 


high  and  seven  inches  wide,  bent  perpendicularly.  A  hole  two 
inches  in  diameter  is  cut  exactly  in  the  center,  over  which  is 
adapted  a  plano-convex  lens.  To  the  upper  left  hand  corner 


fig-  5- 


Albo-carbon  light  with  Author's  combination  laryngoscopic  condenser. 

of  the  shield  a  jointed  movable  arm  is  attached,  which  supports 
the  reflecting  mirror  at  its  distal  end,  in  such  a  manner,  that  it 
may  be  placed  at  any  angle  in  front  of  the  lens,  thus  reflecting 
the  light  as  desired.  The  shield  is  connected  with  the  carbon 
generator  by  means  of  a  stout  piece  of  wire  bent  into  the  shape 
of  a  horseshoe,  the  ends  of  which  pass  into  small  pieces  of 
tubing  soldered  horizontally,  one  on  each  side  of  the  shield. 
To  the  middle  of  this  horseshoe,  a  ball,  perforated  perpendicu- 
larly and  furnished  with  a  thumb-screw,  is  adapted,  through 
which  a  rod,  situated  between  the  base  of  the  generator  and  the 
burner,  is  passed.  It  is  a  combination  of  Tobold's  pocket  illu- 
minator (the  shield  and  reflector)  and  Mackenzie's  bull-eye  con- 
denser (the  plano-convex  lens). 

The  albo-carbon  light  presents,  in  my  opinion,  many  advan- 
tages over  any  light  at  our  disposal  excepting  electricity.  It 
is  almost  as  white  as  that  of  the  latter,  radiates  less  heat  than 
ordinary  gas  or  oil,  requires  no  attention  further  than  the  occa- 
sional renewal  of  the  carbon  as  it  is  consumed,  and  is  less  ex- 
pensive than  any  of  the  above  methods. 

Where  gas  cannot  be  obtained,  a  student  lamp,  furnished 


OIL.  I 

with  an  Argand  burner,  and  the  combination  of  Tobold's  shield 
and  Mackenzie's  bull-eye  condenser,  described  above,  will  serve 
the  best  purpose.  In  fact,  this  arrangement  presents  advan- 
tages over  ordinary  gas-light  in  whiteness  and  in  the  fact 
that  it  is  portable.  Good  coal  oil,  to  which  a  small  piece  of 
camphor  has  been  added,  will  furnish  a  very  bright  and  pene- 
trating light. 

The  mode  of  attachment  of  the  shield  to  the  lamp  is  the  same 

Fig.  6. 


Author's  combination  of  Tobold's  pocket  illuminator  and  Mackenzie's  bull-eye  condenser. 

as  that  employed  for  the  carbon  generator,  the  perforated  ball 
of  the  arms  being  passed  over  a  perpendicular  rod.  The  latter 
is  inserted  in  the  shade  rest,  instead  of  being  attached  to  the 
stand,  as  in  Tobold's  lamp.  In  this  manner  the  lamp  proper  is 


8  ILLUMINATION. 

connected  with  its  stand  by  only  one  point  of  attachment, 
and  can  be  moved  up  and  down  and  turned  on  the  stand  shaft, 
without  disturbing  the  relative  positions  of  the  light  and  shield. 
The  oxy-hydrogen  light  is  used  by  a  few  specialists  on  account 
of  its  brilliancy  and  its  white  color,  but  it  is  very  irregular  in 
its  action  and  expensive  to  keep  in  good  condition. 

POSITION   OF  PATIENT  AND  PHYSICIAN. 

When  an  examination  by  reflected  light  is  to  be  made,  the 
patient  should  be  seated,  with  the  lamp,  or  whatever  apparatus 
is  used,  standing  a  short  distance  from  his  right  shoulder.  The 
observer,  seated  in  front  of  his  patient,  with  one  knee  on  each 
side  of  the  latter's  knees,  places  his  eye  behind  the  perforation 
in  the  reflector,  if  it  is  connected  with  the  lamp,  or  adjusts  this 
instrument  so  as  to  bring  the  hole  before  his  eye,  if  the  head- 
band arrangement  is  used.  In  order  to  obtain  the  greatest  ad- 
vantage of  the  rays  furnished  by  the  flame,  the  reflector  must 
be  so  adjusted  as  to  receive  them  accurately,  that  is  to  say,  the 
center  of  the  disk  formed  by  the  rays  must  correspond  with 
the  middle  of  the  mirror.  This  fact  holds  good  also  in  directing 
the  reflected  light  towards  the  cavity  to  be  examined.  In  an- 
terior rhinoscopy,  whichever  fossa  is  to  be  illuminated  should 
correspond  with  the  center  of  the  reflected  beam,  while  in  pos- 
terior rhinoscopy  and  laryngoscopy  the  mirror  in  the  oral  cavity 
should  hold  the  same  relation  with  it.  When  the  forehead  re- 
flector is  used,  the  head  of  the  observer  must  consequently  be 
held  very  steadily  when  he  has  succeeded  in  concentrating  the 
reflected  light  on  the  desired  spot. 

At  times  the  patient  has  a  tendency  to  move  his  head  out  of  the 
line  of  vision.  This  can  be  easily  mastered,  by  supporting 
his  chin  with  the  middle  finger  of  the  hand  holding  the  tongue 
or  the  tongue  depressor.  A  hold  is  thus  secured  on  the  lower 
jaw,  through  which  the  motions  of  his  head  can  be  controlled. 


ELECTRICITY. 
ELECTRICITY. 

Having  described  the  methods  now  at  our  disposal  for  the 
illumination  of  the  nose  and  throat,  it  might  not  be  amiss  to 
review  briefly  the  past  and  present  of  that  light  which  will,  at 
an  early  date,  supplant  them  all. 

As  stated  before,  electric  light  was  one  of  the  agents  tried 
by  Garcia  in  his  efforts  to  illuminate  the  larynx  by  artificial 
means.  The  infancy  of  laryngoscopy  was  thus  associated  with 
what  will  prove,  in  the  near  future,  a  great  step  towards  its  per- 
fection. It  was  not  until  lately,  however,  that  such  hopes  could 
be  entertained  by  the  enthusiastic  exponents  of  this  branch  of 
medicine.  Many  drawbacks  militated  against  its  use.  Galvanic 
batteries  were  not  only  very  costly,  but  they  required  much 
personal  attention,  and  the  polarization  of  the  cells  made  them 
very  unreliable;  dynamo-electric  machines,  whether  furnished 
with  simple  carbon  points  or  arc-light  lamps,  produced  an  un- 
steady and  flickering  light,  not  to  speak  of  many  other  disad- 
vantages. It  is  only  since  the  invention  of  the  telephone  that 
a  wholesome  awakening  has  taken  place  in  electric  science, 
through  which  great  progress  has  been  made  in  electric  illumi- 
nation. The  invention  of  the  incandescent  lamp,  and  the  im- 
provements in  dynamos,  did  away  with  many  of  the  objection- 
able features,  but  it  is  only  lately  that  the  last  obstacle  which 
rendered  its  employment  in  laryngoscopy  impracticable,  was 
overcome.  The  steadiness  of  the  light  had  been  much  improv- 
ed, but  it  was  far  from  perfect  enough  to  render  it  applicable  to 
our  purpose.  Plante,  the  distinguished  French  scientist,  demon- 
strated that  electricity,  generated  by  whatever  means,  could  be 
stored  for  use  as  required,  and  produced  his  "  storage  battery  " 
or  "accumulator."  Such  an  instrument  had  been  constructed 
before,  but  its  powers  of  retention  were  so  limited  that  no  prac- 
tical benefit  could  be  derived  from  it.  Plante's  "accumulator" 


10 


ILLUMINATION. 


was  not  only  able  to  store  electricity  for  prolonged  usage, 
but  it  presented  an  advantage  of  the  greatest  importance  in 
electric  lighting;  it  only  allowed  this  element  to  flow  from 
its  plates  in  a  steady  and  regular  stream,  obviating  com- 
pletely the  unsteadiness  inseparable  from  it  when  run  by 
the  direct  dynamo  current.  Since  then,  the  efficiency  of  the 
storage  battery  has  been  much  increased,  and  while  being 


Fig.  7. 


Author's  lamp  for  electric  illumination,     a    Storage  Tjattery.     6.  Incandescent  lamp.     C.  Circuit  closer. 

made  more  durable,  its  cost  has  been  relatively  much  reduced. 
Being  desirous  of  testing  the  practical  application  of  accu- 
mulators, I  removed  the  reservoir,  wick  cylinder,  and  burner 
of  a  lamp  such  as  that  in  Fig.  6,  and  attached  a  small  Edison 
incandescent  lamp  to  the  end  of  the  oil  pipe,  using  the  latter 
as  conduit  for  the  (well  insulated)  wires.  The  other  parts  of 


ELECTRIC   ILLUMINATOR.  11 

the  instrument  were  not  disturbed,  and  all  freedom  of  motion 
preserved.  Connecting  the  wires  with  a  series  of  accumula- 
tors, I  obtained  an  illumination  which  nothing  could  surpass  in 
brilliancy.  Unfortunately,  such  an  arrangement  is  as  yet  too 
expensive  to  warrant  its  constant  use,  while  the  large  number 
of  accumulators  necessary  to  overcome  the  resistance  of  the 
lamp  makes  their  frequent  transportation  for  the  purpose  of 
re-charging  an  annoying  feature.  For  our  purpose,  the 
advantages  of  the  storage  battery  can  hardly  be  appre- 
ciated, and  it  is  to  be  hoped  that  the  obstacles  yet  mili- 
tating against  its  general  use  will  soon  be  overcome. 


CHAPTER  II. 

ANATOMY  AND  PHYSIOLOGY  OF   THE  NASAL   CAVITIES. 


ANATOMY. 

THE  ANTERIOR  NASAL,  CAVITIES. 

THE  anterior  nasal  cavities  extend  from  the  margin  of  the 
nostrils  to  the  anterior  limit  of  the  pharyngeal  vault  or  poste- 
rior nasal  cavity.  Their  roof,  about  one-quarter  of  an  inch 
wide,  and  one  inch  and  a  half  long,  is  formed  by  the  cribriform 
plate  of  the  ethmoid  and  the  nasal  bones;  their  walls,  about 
-one  and  a  half  inches  high,  slanting  outwards  and  downwards, 
by  the  vertical  plates  of  the  palate  and  the  nasal  surfaces  of  the 
superior  maxillary  bones,  and  their  floor,  about  one  inch  wide, 
by  the  horizontal  or  palatal  processes  of  the  same  bones.  Their 
general  shape  is  that  of  a  wedge  with  rounded  edges.  In  front, 
the  bony  framework  is  replaced  by  cartilaginous  plates,  and 
that  part  of  each  of  the  cavities  which  they  cover  is  called  the 
vestibule. 

The  anterior  nasal  cavities  are  separated  by  an  upright  par- 
tition, the  septum,  formed  by  the  perpendicular  plate  of  the 
ethmoid  above,  the  vomer  behind,  and  the  septal  cartilage  in 
front.  These  are  articulated  at  their  edges,  and  form  a  thin 
plate  which  serves  as  a  smooth  inner  wall  to  each  cavity.  It 
is  seldom  perfectly  straight,  its  center  generally  bending  either 
to  the  one  side  or  to  the  other — most  frequently  to  the  left.  Its 
thickness,  which  in  front  is  about  one-tenth  of  an  inch,  increases 
slightly  from  before  backwards,  until  it  becomes  one-eighth  of 
an  inch  thick  at  its  posterior  margin. 

The  anterior  nasal  cavities  are  open  from  front  to  back.  The 
front  apertures  or  nostrils,  elliptical  in  shape,  are  called  the 
(12) 


ANATOMY  OF  THE  ANTERIOR  NASAL   CAVITIES.  13 

anterior  nares ;  those  facing  the  pharyngeal  vault,  broader  and 
higher,  and  shaped  somewhat  like  a  pigeon's  egg,  the  posterior 
nares. 

From  the  wall  on  each  side  and  directed  towards  the  septum, 
but  not  touching  it,  stand  out  three  horizontal,  shelf -like  prom- 
inences, the  superior,  middle  and  inferior  turbinated  bones.  The 
superior,  the  smaller  of  the  three,  protrudes  perpendicularly 
from  the  roof,  and  forms  between  its  edge  and  the  slanting  wall 
of  the  nose  the  superior  meatus,  into  which  the  canal  of  the 
sphetioidal  sinus  opens.  The  middle,  much  larger,  and  with  its 
edge  curled  under,  stands  out  obliquely  downwards  and  forms 
the  middle  meatus,  into  which  the  infundibulum,  the  canal  of  the 
frontal  sinus  and  the  orifice  of  the  antrum,  immediately  adjoin- 
ing, have  their  apertures ;  the  former  being  partially  hidden  by 
a  projecting  fold  of  mucous  membrane,  and  the  latter  contracted 
to  a  small  circular  opening.  The  inferior  turbinated  bone  is 
somewhat  larger  than  the  middle;  its  surface  approximates 
more  the  horizontal,  while  the  curl  of  its  edge  is  more  accen- 
tuated, excepting  at  its  anterior  portion,  where  it  gradually 
tapers  until  united  with  the  wall.  The  space  under  it  is  the 
inferior  meatus,  into  which  the  nasal  duct,  the  canal  by  which 
the  lachrymal  sac  is  connected  with  the  nose,  opens,  by  a  some- 
what expanded  orifice  provided  with  an  imperfect  valve  formed 
by  the  mucous  membrane. 

The  accessory  cavities,  with  which  the  two  upper  meatuses 
are  connected  by  canals,  the  sphenoidal  sinuses,  the  frontal 
sinuses,  and  the  antra  of  Highmore  or  maxillary  sinuses, 
although  not  forming  a  part  of  the  nasal  fossae  proper,  often 
become  involved  in  the  affections  to  which  these  are  liable. 

The  sphenoidal  sinuses  are  two  irregular  cavities,  usually 
about  the  size  of  an  acorn,  separated  from  each  other  by  a  thin 
osseous  lamina.  They  are  situated  immediately  behind  the  su- 
perior meatuses,  a  thin  plate  of  bone  separating  them  from  the 


14  ANATOMY  AND  PHYSIOLOGY  OF  THE  NASAL  CAVITIES. 

latter.  The  so-called  canal  connecting  each  sinus  with  its  ad- 
joining meatus  is  a  perforation  through  this  plate,  at  its  upper 
junction  with  the  roofs  of  each  cavity,  large  enough  to  allow 
the  passage  of  a  darning  needle.  The  roof  of  each  sinus, 
usually  about  one-twelfth  of  an  inch  thick  in  the  adult  at  its 
thinnest  portion,  separates  it  from  the  base  of  the  brain. 

The  frontal  sinuses,  much  larger  than  the  sphenoidal,  are 
situated  between  the  two  tables  of  the  skull  in  the  frontal  bone 
immediately  over  the  upper  and  front  portion  of  the  nasal 
cavity,  and  extend  some  distance  over  each  orbit.  They  -give 
rise  to  the  prominences  above  the  root  of  the  nose.  They  are 
irregular  in  shape,  separated  from  each  other  by  a  bony  par- 
tition, and  are  occasionally  subdivided  into  smaller  cavities 
by  osseous  lamina?.  They  are  generally  absent  in  children, 
developing  and  increasing  in  size  as  age  advances.  The  bony 
plate  forming  their  posterior  wall  separates  them  from  the  ante- 
rior convolutions  of  the  brain,  and  is  very  thin  where  their  an- 
tero-posterior  diameter  is  broadest.  The  infundibulum,  by 
which  each  sinus  communicates  with  the  middle  meatus,  is  a 
narrow  canal  which  begins  at  the  junction  of  its  floor  with  the 
inner  wall,  and  is  directed  downwards  and  backwards. 

The  maxillary  sinuses  or  antra  of  Hiahmore,  are  two  large 
cavities  in  the  bodies  of  the  superior  maxillary  bones  immedi- 
ately adjoining  the  nasal  cavities,  the  outer  walls  of  which  form 
their  internal  boundary.  The  floor  of  each  antrum  is  formed 
by  the  alveolar  process,  the  roots  of  the  first  and  second  molar 
teeth  sometimes  penetrating  into  it.  The  roof  is  formed  by  the 
floor  of  the  orbit,  its  external  wall  by  the  facial,  and  its  posterior 
by  the  zygomatic  surfaces  of  the  superior  maxilla.  The  aperture 
by  which  it  opens  into  the  middle  meatus  is  situated  near  its 
upper  part  and  is  large  enough  to  admit  the  end  of  an  ordinary 
probe. 

The  mucous  membrane  lining  the  nasal  cavities  is  sometimes 


ANATOMY   OF  THE   ANTERIOR  NASAL   CAVITIES.  15 

called  pituitary,  which  means  "phlegm  producing,"  and  ScJinei- 
clerian,  from  Schneider,  who  first  showed  that  the  nasal  secretion 
was  produced  by  the  mucous  membrane,  and  not  by  the  brain. 
Jt  is  continuous  with  the  skin  of  the  nostrils  in  front,  and 
with  the  mucous  membrane  of  the  pharyngeal  vault  behind, 
adheres  closely  to  the  bones  or  cartilages  which  it  covers,  and 
varies  greatly  in  thickness  in  the  different  localities.  It  is 
thickest  over  the  turbinated  bones,  somewhat  thinner  over  the 
septum,  very  thin  on  the  nasal  floor,  the  under  surface  of  the 
turbinated  bones,  and  the  accessory  cavities,  to  which  it  is  dis- 
tributed by  continuity  through  the  apertures  by  which  these 
are  connected  with  the  nasal  cavities.  Its  color  also  varies  in 
different  regions.  The  upper  portion,  called  the  olfactory  region, 
including  the  roof,  the  superior  turbinated  bone,  the  superior 
meatus,  the  upper  third  of  the  surface  of  the  middle  turbi- 
nated and  the  corresponding  portion  of  the  septum,  are  of  a 
yellowish  pink.  Below  this  limit,  the  portion  called  the  respi- 
ratory region,  the  membrane  is  light  pink;  at  the  posterior  ends 
of  the  turbinated  bones  this  color  assumes  a  whitish  hue  which 
increases  in  intensity  vrhen  hypertrophic  changes  take  place. 
In  the  accessory  cavities  the  membrane  is  of  a  pale  pink.  The 
depth  of  coloring  is  influenced  by  the  condition  of  the  blood 
of  the  subject:  in  anemia,  it  is  paler,  the  underlying  bone 
giving  the  transparent  membrane  a  yellowish  tint  in  localities 
where  it  is  thin ;  in  plethora,  the  general  color  may  even  be 
dark  pink,  and  the  variations  in  the  different  regions  very 
slight. 

In  the  olfactory  region,  to  which  the  branches  of  the  olfactory 
nerve  are  distributed,  the  mucous  membrane  is  covered  by 
tesselated  epithelium;  below  this  and  throughout  the  whole 
extent  of  the  respiratory  region,  excepting  the  vestibule  and  the 
cartilaginous  portion  of  the  nose  just  above  the  nostrils,  which 
are  also  covered  by  tesselated  epithelium,  the  mucous  membrane 


1G  ANATOMY  AND  PHYSIOLOGY  OF  THE  NASAL  CAVITIES. 

is  covered  by  ciliated  epithelium,  so  called  because  it  is  furnished 
with  fine  hair-like  processes  which  possess  the  power  of  vibra- 
ting to  and  fro.  The  mucous  membrane  proper,  immediately 
under  these  two  varieties  of  epithelial  covering,  is  composed  of 
the  usual  elements,  connective  and  elastic  tissue,  bloodvessels, 
muscular  fibres,  etc.,  and  is  traversed  by  the  ducts  of  two  kinds 
of  glands,  serous  and  mucous,  which  have  their  origin  in  the 
third  or  submucous  layer,  and  their  openings  between  the 
epithelial  cells.  Although  closely  distributed  throughout  the 
whole  nasal  membrane,  they  are  most  numerous  at  the  middle 
and  back  parts  of  the  cavities,  and  largest  at  the  lower  and 
back  part  of  the  septum. 

The  third  or  sub-mucous  layer,  lies  in  contact  with  the  peri- 
osteum of  the  osseous  walls  and  the  perichondrium  of  the 
cartilaginous.  It  is  principally  composed  of  an  erectile  caver- 
nous tissue,  especially  thick  over  the  inferior  turbinated  bone 
and  the  lower  part  of  the  septum,  resembling  very  much  the 
corpora  cavernosa  of  the  penis,  hence  called  by  Bigelow,  of 
Boston,  the  turlinated  corpora  cavernosa.  It  is  composed  of 
large  venous  sinuses,  which  can  be  suddenly  filled  by  the  capil- 
laries which  open  abruptly  into  them,  causing  distension  and 
erection. 

Arteries. — The  arterial  supply  of  the  nasal  fossae  is  as 
follows : — The  roof,  by  the  ophthalmic,  small  ramifications  of 
which  pass  through  the  apertures  in  the  cribriform  plate,  and 
descend  a  short  distance  down  the  septum  and  the  walls  of 
the  fossae.  They  also  supply  the  frontal  sinuses. 

The  turbinated  bones,  the  meatuses  and  the  septum  are  sup- 
plied by  the  spheno-palatine  branches  of  the  internal  maxillary, 
which  enter  the  nasal  cavity  by  the  spheno-palatine  foramina 
at  the  back  part  of  the  superior  meatuses,  where  they  each  di- 
vide into  two  branches :  one  internal,  the  artery  of  the  septum, 
passes  obliquely  downwards  and  forwards  along  the  septum, 


ANATOMY  OF   THE  POSTEEIOE   NASAL   CAVITY.  17 

supplies  the  mucous  membrane  and  anastomoses  with  the  nasal 
branch  of  the  ophthalmic  alluded  to  above ;  and  one  external, 
which  subdivides  into  two  or  three  branches  and  supplies  the 
mucous  membrane  covering  the  lateral  wall  of  the  nose,  the 
antruni,  and  the  sphenoidal  sinus.  The  anterior  portion  of  the 
septum  is  supplied  by  the  "artery  of  the  septum,"  a  branch  of 
the  superior  coronary,  which  enters  the  nose  at  the  junction  of 
the  nostril  with  the  lip.  The  arterial  supply  of  the  nasal  mu- 
cous membrane  is  a  close  and  compact  network  of  vessels,  and 
readily  explains  the  copious  hemorrhages  accompanying  opera- 
tions in  the  nasal  fossae. 

Nerves. — The  nerves  of  the  nasal  fossa3  are  the  olfactory,  the 
special  nerve  of  the  sense  of  smell,  which  is  distributed  over 
the  upper  third  of  the  septum,  and  over  the  superior  and  upper 
part  of  the  middle  turbinated  bones.  The  middle  and  poste- 
rior part  of  the  septum,  the  lower  edge  of  the  superior,  and 
the  surface  of  the  middle  and  inferior  turbinated  bones,  are  sup- 
plied by  the  nasal  branches  of  the  spheno-palatine  ganglion  of 
the  sympathetic,  which  enter  the  nasal  cavity  J)y  the  spheno- 
palatine  foramina  along  with  the  arteries.  The  vidian  also 
supplies  the  upper  and  back  part  of  the  septum  and  the  mucous 
membrane  of  the  superior  turbinated  bones.  The  upper  and 
anterior  part  of  the  septum  and  the  outer  wall  of  the  nasal 
fossae,  the  anterior  surface  of  the  inferior  turbinated  bone  and 
the  floor  of  the  nose,  are  supplied  by  the  nasal  branch  of  the 
fifth  pair,  which  enters  the  nasal  cavity  through  a  slit  by  the 
side  of  the  crista  galli,  supplying  them  with  general  sensibility. 

THE  POSTEEIOR  NASAL  CAVITY. 

The  posterior  nasal  cavity  extends  from  the  posterior  limit 
of  the  anterior  nasal  cavities,  with  the  external  walls  of  which 
it  is  continuous,  to  an  imaginary  line  passing  horizontally  under 
the  free  border  of  the  soft  palate.  Its  roof,  at  first  horizontal, 

2 


18  ANATOMY  AND   PHYSIOLOGY   OF   THE   NASAL  CAVITIES. 

gradually  curves  downward  posteriorly  and  on  each  side,  form- 
ing three  perpendicular  walls  supporting  a  half  dome  which 
faces  the  posterior  nares.  This  half  dome  is  called  the  pha- 
ryngeal  vault,  and  forms  the  top  of  the  pharynx.  Its  floor  is  the 
upper  surface  of  the  soft  palate,  which  is  continuous  posteriorly 
with  the  floor  of  the  nose.  The  space  between  the  free  border 
of  the  soft  palate  and  the  posterior  wall  of  the  naso-pharynx 
is  called  the  isthmus,  which  is  closed,  when,  during  the  act  of 
deglutition  the  velum  palati  is  approximated  to  the  pharynx. 

The  osseous  relations  of  the  pharyngeal  vault  are :  above,  the 
body  of  the  sphenoid  and  the  basilar  process  of  the  occipital 
bone ;  posteriorly,  the  anterior  surface  of  the  first  cervical  ver- 
tebra ;  laterally,  the  internal  pterygoid  plates  of  the  sphenoid 
and  the  petrous  portions  of  the  temporal  bones. 

Its  mucous  membrane  is  continuous  with  that  of  the  nose,  but 
is  furnished  with  a  much  greater  number  of  glands.  These  are 
of  two  kinds,  conglomerate  and  follicular,  the  former  being  most 
abundant  behind  the  eminences  containing  the  orifices  of  the 
Eustachian  tubes  on  each  side,  and  on  the  upper  surface  of  the 
soft  palate,  where  they  are  clustered  together.  The  follicular 
glands  form,  on  the  posterior  wall  at  the  lower  part  of  the 
vault  what  Luschka  has  named  the  pliarynyeal  tonsil.  It  is 
composed  of  follicles,  more  or  less  compactly  united.  Its  sur- 
face is  dotted  by  a  number  of  small  prominences,  the  openings 
of  the  glandule,  and  shows  numerous  depressions  and  crypts. 
Its  thickness  is  about  one-tenth  of  an  inch,  and  it  extends  on 
each  side  to  a  deep  groove,  which  separates  it  from  the  orifice 
of  the  Eustachian  tube,  called  the  fossa  of  Hosenmuller. 

The  pink  color  of  the  pharyngeal  vault  is  somewhat  darker 
than  that  of  the  nasal  fossa?.  The  prominences  of  the  Eusta- 
chian tubes,  however,  are  of  a  very  light  pink,  which  becomes 
yellowish  around  the  orifices. 

Arteries. — The  greater  portion  of  the  posterior  nasal  cavity 


PHYSIOLOGY  OF  THE   NASAL   CAVITIES.  19 

is  supplied  by  the  ascending  pharyngeal,  which  is  derived  from 
the  external  carotid.  Its  anterior  portion  receives  the  termi- 
nal branches  of  the  spheno-palatine  and  the  vidian  already 
described. 

Nerves. — The  roof  and  the  Eustachian  prominences  are  sup- 
plied by  the  pharyngeal  branches  of  the  second  division  of  the 
fifth ;  the  floor  by  its  posterior  palatine  branches,  and  the  wall 
by  twigs  of  the  glosso-pharyngeal  and  spinal  accessory,  and 
superior  cervical  of  the  sympathetic. 

PHYSIOLOGY. 

The  functions  of  the  nasal  cavities  are  the  following: — 
they  are  the  seat  of  the  sense  of  smell;  they  elevate  the  tem- 
perature of  the  inhaled  air,  give  it  moisture  and  purify  it 
by  arresting  what  particles  of  dust  or  other  substances  it  may 
contain ;  they  serve  as  resonance  cavities  for  the  voice. 

The  mucous  membrane  covering  the  superior  and  the  upper 
part  of  the  middle  turbinated  bones  contains  the  filaments  of 
the  olfactory  nerves.  It  is  known  as  the  olfactory  membrane, 
and  receives  the  impression  made  by  the  odoriferous  particles. 
In  order  to  produce  an  olfactory  impression  the  emanations  of 
the  odoriferous  body  must  be  drawn  freely  through  the  nose. 
When  they  reach  the  olfactory  membrane  they  are  dissolved  in 
the  secretion  covering  it,  and  are  thus  brought  in  relation  with 
its  nerves.  Any  morbid  condition  decreasing  the  area  of  the 
nasal  cavities  or  inducing  an  absence  of  secretion,  will  con- 
sequently affect  the  sense  of  smell. 

When  the  temperature  of  the  air  is  several  degrees  lower 
than  that  of  the  blood,  a  slight  increase  in  its  temperature 
may  be  noticed  after  it  has  passed  the  nasal  cavity  on  its  way 
to  the  lungs;  the  greater  the  difference  between  air  and  blood, 
the  more  this  increase  will  be  marked,  until  in  very  cold 
weather,  the  air  will  have  become  comparatively  warm  before 


20  ANATOMY  AND  PHYSIOLOGY  OF  THE  NASAL  CAVITIES. 

reaching  the  larynx.  "Were  this  not  the  case,  the  inhabitants 
of  high  latitudes  could  not  endure  the  intensity  of  the  cold. 
This  warmth  is  not  only  communicated  to  the  air  by  the  very 
vascular  and  tortuous  fossa?,  but  is  also  obtained  by  admixture 
with  the  watery  secretion  of  the  serous  glands  and  the  watery 
vapor  exhaled  by  the  lungs,  deposited  on  the  surface  of  the  nasal 
membrane  and  kept  warm  by  the  underlying  arterial  supply. 
Thus  its  temperature  is  not  only  raised  but  it  is  also  made  moist 
and  better  prepared  to  meet  the  delicate  bronchial  surfaces. 

Around  the  margin  of  the  nostrils  are  little  hairs  termed 
vibrlssce.  The  object  of  these  is  to  arrest  the  larger  particles 
of  dust  or  other  foreign  substances  that  the  air  might  contain. 
Finer  particles  however,  are  not  interfered  with  on  their  pass- 
age through  the  nostrils,  but  having  passed  these,  meet  the 
surfaces  of  the  fossa?,  made  adhesive  by  the  secretion  of  the 
mucous  glands,  and  adhere  to  them.  The  constant  to  and  fro 
motion  of  the  cllise  of  the  ciliated  epithelium  propels  the 
mucus  containing  them  towards  the  nostrils,  and  the  desire 
to  "blow"  the  nose  is  experienced. 

When  through  loss  of  the  turbinated  bones,  atrophy  of  the 
mucous  membrane  or  other  causes,  the  nasal  fossa?  become  too 
patent,  these  conditions  are  not  fulfilled,  and  the  pharynx, 
larynx,  and  lungs,  are  constantly  exposed  to  the  effects  of  cold 
dry  air  filled  with  any  extraneous  matter  that  may  be  floating 
in  it.  Again,  when  the  abnormal  condition  is  one  interfering 
with  nasal  respiration  making  mouth  breathing  a  necessity, 
the  same  dangers  are  incurred,  the  physiological  functions  of 
the  nasal  cavities  being  completely  omitted. 

That  the  nasal  cavities  influence  the  resonance  of  the  voice 
can  readily  be  ascertained  by  closing  the  nostrils  and  uttering 
a  few  words.  When  a  sound  is  produced,  the  air  in  the  cavi- 
ties, as  well  as  that  in  the  mouth,  is  thrown  into  vibration, 
and  if  the  condition  of  the  former  is  such  as  to  not  interfere 


PHYSIOLOGY  OF  THE   NASAL   CAVITIES.  '21 

with  the  passage  of  the  sound  waves  emanating  from  the 
larynx,  the  oral  note  will  be  clear  and  penetrating,  having 
acquired  resonance  and  body  through  the  additional  vibration 
of  the  air  in  the  nasal  spaces.  If  t  the  nose  be  closed  either  by 
the  fingers  or  some  abnormal  condition  of  its  walls  or  lining 
membrane,  the  air  contained  behind  the  seat  of  obstruction 
will  also  be  thrown  into  vibration,  but  being  imprisoned  there, 
will  not  contribute  to  the  quality  of  the  note.  The  "nasal 
twang"  will  be  produced  and  the  note  will  be  devoid  of  volume 
and  character.  The  same  degree  of  freedom  for  the  passage 
of  sound  is  not  always  required  however.  In  the  nasal  con- 
sonant m,  for  instance,  the  cavities  must  be  clear  of  all  obstruc- 
tion, and  closure  of  the  nostrils  causes  it  to  be  pronounced  eb, 
while  the  lingual  I  can  be  pronounced  with  nose  closed  with 
no  change  in  the  pronunciation,  the  sound  alone  being  devoid 
of  proper  quality.  The  "regulator"  in  this  case  is  the  soft 
palate.  When  m  is  pronounced  the  soft  palate  stands  some 
distance  from  the  wall  of  the  pharynx  giving  ample  room  for 
the  combination  of  oral  and  nasal  vibrations  and  for  the  free 
passage  of  the  second  sound  of  the  letter,  which  is  pronounced 
through  the  nose.  When  /  is  pronounced,  the  soft  palate  ap- 
proaches the  pharynx,  the  resonance  of  the  cavities  being  only 
necessary  for  the  quality  of  sound.  If  it  were  in  the  same 
position  as  for  w,  the  second  sound  of  the  letter,  which  is 
entirely  pronounced  through  the  mouth,  and  is  formed  by  press- 
ing the  end  of  the  tongue  against  the  front  part  of  the  palate, 
would  not  be  heard,  the  greater  part  of  the  sound  waves 
having  escaped  through  the  nose,  without,  of  course,  being 
influenced  by  the  position  of  the  tongue. 

Purity  of  voice  and  enunciation,  depends  largely  upon  the 
condition  of  the  nasal  cavities  and  of  the  soft  palate,  and 
requires  the  absence  of  all  obstructions  of  the  former,  or  of 
any  condition  interfering  with  the  free  motion  of  the  latter. 


CHAPTER  III. 

RHINOSCOPY. 

RHINOSCOPY  is  the  term  applied  to  the  optical  examination 
of  the  nose.  When  the  examination  is  made  by  looking 
directly  into  the  nostril,  it  is  called  anterior  rhinoscopy;  when 
it  is  made  with  the  aid  of  a  mirror  passed  through  the  opened 
mouth  and  held  behind  the  soft  palate,  it  is  called  posterior 
rhinoscopy,  by  means  of  which  a  reflected  view  of  the  pos- 
terior aspect  of  the  nasal  passages  is  obtained. 

ANTEEIOR   EHINOSCOPY. 

In  order  to  illuminate  the  anterior  nares  properly  and 
facilitate  inspection,  their  aperture  must  be  dilated.  Several 
instruments  are  at  our  disposal  for  that  purpose,  called  nasal 
dilators,  a  misnomer,  for  the  nostrils  alone  are  dilated  and 
not  the  nose.  The  instrument  is  correctly  called  by  some 
authors  "nostril  dilator,"  a  term  which  should  replace  the  other. 
Gi-oodwillie's,  with  three  blades  is,  in  my  opinion,  the  most 
efficient  instrument,  being  light  and  self -retaining.  As  origi- 
nally constructed,  however,  it  was  rather  inconvenient  to 
manipulate.  A  firm  grasp  being  obtained  with  difficulty,  the 
instrument  frequently  rotated  on  its  axis  as  its  blades  were 
being  inserted  in  the  nostril.  Dr.  Alex.  MacCoy,  of  this  city, 
had  a  finger  rest  placed  on  each  lateral  branch,  rendering 
its  manipulation  as  easy  as  that  of  any  other.  Another  good 
instrument  is  Bosworth's,  shown  in  Fig.  8.  It  is  light  and 
easily  handled. 

When  the  nose  is  sensitive,  dilators  which  are  opened  by 

the  spring  of  the  blades,  such  as  the  above,  give  rise  to  severe 
(22) 


NASAL  DILATORS. 


23 


pain,  especially  if  allowed  to  open  suddenly.  I  have  added  a 
movable  threaded  rod  with  a  finger  screw  at  each  end,  across 
the  lateral  branches  of  Goodwillie's  instrument,  by  which  the 
expansion  of  its  blades  can  be  regulated.  By  bending  the 


Fig.  8. 


Bosworth's  nostril  dilator. 


tips  of  the  rod,  two  rings  are  formed,  one  at  each  end,  which 
secure  the  screws  and  serve  for  a  hook  by  which  the  instru- 


Fig.  9. 


Author's  hook  to  elevate  the  dilator  and  the  tip  of  the  nose. 
Fig.  10. 


Author's  modification  of  Goodwillie's  nostril  dilator. 


ment  can,  if  necessary,  be  connected  with  a  head  band  to 
elevate  the  tip  of  the  nose.  I  have  also  altered  the  shape  of 
the  blades  by  making  their  central  depression  much  more 
marked  and  their  ends  more  pointed.  The  instrument,  thus 
modified,  will  be  held  firmly  in  the  nostril,  occasion  no  pain, 


2-4  RHINOSCOPY. 

and  be  applicable  in  all  cases,  thus  avoiding  the  necessity  of 
a  set  of  different  sizes.  It  should  be  manipulated  with  one 
hand,  the  thumb  and  middle  finger  pressing  on  the  finger 
rests,  and  the  index  regulating  the  screw. 

Although  apparently  easy,  the  manipulation  of  a  nostril 
dilator  requires  much  care.  The  instrument  is  designed 
exclusively  to  expand  the  membrano-cartilaginous  part  of 
the  nostril;  if  it  were  allowed  to  enter  beyond  this  and  to 
reach  the  isthmus  formed  by  the  unyielding  cartilaginous 
septum  and  the  nasal  margin  of  the  ascending  branch  of  the 
upper  maxillary  bone,  it  would  cause  pain  without  dilating 
in  the  least  the  opening  between  them.  It  should  never  be 
inserted  deeper  than  one-half  inch,  a  quarter  of  an  inch  being 
sufficient  in  most  cases.  One  blade  should  rest  under  the  tip 
of  the  nose  and  the  other  against  the  edge  of  the  floor  of  the 
nose.  The  parts  will  not  be  distorted  as  when  the  blades  are 
applied  one  against  the  lower  edge  of  the  septum,  and  the 
other  against  the  soft  cartilaginous  wing.  The  shape  of  the 
aperture  will  facilitate  the  penetration  of  light  and  the  intro- 
duction of  instruments,  and  the  dilator  will  be  held  firmly. 
Goodwillie's  presents  an  advantage  here,  its  third  or  middle 
blade  pressing  against  the  wing  just  sufficiently  to  increase 
the  lateral  diameter  of  the  opening,  without  disturbing  the 
relation  of  the  parts  to  each  other. 

The  patient's  head  being  tilted  backward  so  as  to  bring  the 
axis  of  the  nasal  cavities  on  a  line  with  the  observer's  eye,  the 
light  is  directed  into  the  nostril  to  be  examined.  The  blades 
of  the  dilator  are  then  inserted,  and  when  in  the  proper  posi- 
tion allowed  to  open  gently.  If  a  regulating  screw  be  con- 
nected with  it,  the  expansion  of  the  blades  can  be  arrested  as 
soon  as  the  nostril  is  dilated  sufficiently  and  the  instrument 
retained  by  its  resiliency. 

It  is  sometimes  necessary  to  raise  the  tip  of  the  nose  to 


THE  ANTERIOR  RHINOSCOPIC  IMAGE.  ZD 

increase  the  field;  this  can  be  done,  either  by  tilting  the 
dilator  upward,  or  by  resting  the  fingers  against  the  forehead 
and  raising  the  tip  with  the  thumb.  This  will  enable  the 
observer  to  rotate  the  head  of  the  patient  and  bring  success- 
ively all  the  different  parts  of  the  cavity  to  be  examined 
under  the  light.  In  operations,  it  is  sometimes  necessary  to 
keep  the  nose  tilted  upward  for  some  time,  not  only  to 
facilitate  illumination,  but  also  to  give  the  operator  the 
freedom  of  his  hands  and  more  working  space.  The  hook 
shown  in  Fig.  9  will  be  found  very  convenient.  It  is  adapt- 
able to  any  reflector  head-band,  or  may  be  connected  with  a 
piece  of  tape  attached  around  the  patient's  head. 

An  ordinary  probe  is  very  useful  in  anterior  rhinoscopy  to 
ascertain  the  conformation  of  prominences,  their  density,  the 
relation  of  parts  to  each  other,  etc. 

THE   AXTERIOK   RHINOSCOPIC   IMAGE. 

The  image  brought  to  view  by  anterior  rhinoscopy  is  gener- 
ally a  limited  one.  In  exceptional  cases,  especially  in  those 
where  the  septum  is  strongly  deflected  to  one  side,  or  where 
atrophy  of  the  lining  membrane  has  taken  place,  the  entire 
surface  of  the  nasal  cavity  can  be  seen,  including  that  part  of 
the  pharynx  above  the  line  of  the  palate.  But  in  ordinary 
cases,  the  view  can  be  much  extended  by  moving  the  head  in 
different  directions.  With  the  head  in  the  position  described 
in  the  preceding  paragraph,  the  parts  seen  will  be  the  ante- 
rior portions  of  the  middle  and  inferior  turbinated  bones  on 
one  side,  and  the  wall  of  the  septum  on  the  other.  Tilting 
the  head  backward  somewhat  more,  the  middle  turbinated 
bone  will  be  seen  more  extensively,  while  the  roof,  the  supe- 
rior turbinated  bone,  and  the  anterior  portion  of  the  nasal 
cavity  will  come  into  view.  Lowering  the  head  will  cause 
an  entirely  different  image,  the  middle  turbinated  and  all 


2G 


RHINOSCOPY. 


above  it  disappearing  from  view,  and  the  inferior  turbinated, 
the  inferior  nieatus,  and  the  floor  of  the  nose  coming  into 
full  sight.  In  their  normal  condition,  these  parts  are  light 
pink,  with  the  exception  of  the  superior  turbinated  bone  and 
the  roof  of  the  nose,  which  are  yellow.  When  seen  by  a 
yellow  light  the  pink  becomes  darker,  approximating  red. 
This  should  be  borne  in  mind  in  making  a  diagnosis. 

POSTERIOR   RHINOSCOPY. 

The  instruments  necessary  for  examining  the  posterior 
aspect  of  the  nasal  cavities  are,  a  tongue  depressor,  a  post- 
nasal  mirror  and  sometimes,  a  palate  elevator. 

Of  tongue  depressors,  of  which  there  are  many  kinds  at 
our  disposal,  that  shown  in  Fig.  11  is  the  most  satisfactory. 
It  is  heavily  nickel-plated,  easily  kept  clean,  and  takes  firm 
hold  of  the  tongue  by  encircling  within  the  fenestra  in  its 
blade,  a  bulging  portion  of  the  surface  of  that  organ. 

Fig.  ii. 


Tongue-depressor. 

In  introducing  the  tongue-depressor  it  should  be  borne  in 
mind  that  the  organ  at  once  resists  rude  treatment,  and  that 
pressure  on  the  papilla  cireumvallatae  causes  violent  retching 
in  most  cases. 

The  patient  is  requested  to  open  his  mouth  and  the  light  is 


THE  RHINOSCOPE.  27 

directed  into  it.  The  instrument,  held  firmly  (Fig.  13)  with 
the  thumb  resting  just  behind  the  hinge,  is  then  introduced, 
and  when  the  blade  covers  about  tivo-thinls  of  the  tongue, 
firm  pressure  is  exerted,  the  tip  of  the  instrument  being  made 
to  revolve  in  the  arc  of  a  circle  with  its  center  at  the  teeth. 
Sometimes,  much  difficulty  is  experienced  in  depressing  the 
tongue.  The  organ  will  arch  itself  to  a  degree  that  will  make 
it  appear  as  if  it  were  four  times  its  normal  size,  or  its  tip  will 
rest  behind  the  lower  incisors,  and  the  dorsum  will  ascend 
to  the  hard  palate,  completely  preventing  a  view  of  the  phar- 
ynx. This  is  sometimes  due  to  fear,  at  other  times  to  inabil- 
ity to  control  its  movements.  After  a  first  effort,  the  patient 
should  be  allowed  to  rest  for  a  few  moments,  then  requested 
to  open  his  mouth  without  moving  his  tongue,  that  is  to  say, 
to  keep  it  in  the  position  it  held  when  the  mouth  was  closed. 
This  will  generally  succeed.  If  it  does  not,  the  only  way  to 
depress  it,  is  to  fatigue  it  by  continued  pressure.  The  rigid 
muscles  will  soon  give  way. 

The  rhinoscope  is  a  small  plane  mirror  mounted  on  a  wire 
stem  and  furnished  with  a  handle.  Several  sizes  are  made, 
but  the  size  generally  preferred  is  the  No.  1  mirror,  the 


Fig.  12. 


Rhinoscope. 

diameter  of  which  is  one-half  inch.  The  stem  is  curved 
somewhat,  the  line  followed  being  that  of  the  surface  of  the 
tongue.  The  object  of  this  is  to  enable  the  observer  to  hold  the 
mirror  belo\v  the  plane  of  the  soft  palate  (which  would  other- 
wise interfere  with  the  view)  without  causing  the  hand  hold- 
ing the  instrument  to  stand  in  the  way.  The  mirror  must  be 
held  with  its  surface  slanting  somewhat  towards  the  observer, 
so  as  to  enable  him  to  see  the  reflected  image,  while  at  the 


28 


KHIXOSCOPY. 


same  time  illuminating  the  point  examined.  This  brings  its 
lower  edge  behind  the  tongue,  and  the  distance  between  that 
organ  and  the  pharynx  being  rather  less  than  one  inch,  if  the 


Fig.  13. 


Rhinoscope  and  tongue  depressor  in  position. 

diameter  of  the  mirror  were  greater  than  it  is,  its  npper  edge 
would  touch  the  pharynx  and  its  lower  the  base  of  the  tongue, 
causing  retching  and  gagging. 

Occasionally,  through  congenital  malformations,  destructive 
metamorphoses,  etc.,  the  soft  palate  is  either  absent,  or  in  such 
a  condition  that  a  larger  mirror  can  be  used.  These  oppor- 
tunities should  always  be  taken  advantage  of,  a  complete 
image  of  the  posterior  nares  being  seldom  obtainable. 

The  first  requisite  for  making  a  satisfactory  examination  of 
the  posterior  nares  is  to  depress  the  tongue  properly,  exposing 


THE  RHINOSCOPE  29 

as  much  as  possible  of  the  wall  of  the  pharynx.  In  order  to 
leave  the  right  hand  free,  the  tongue  depressor  should  be  held 
with  the  left  hand.  The  mirror,  held  like  a  penholder,  is  then 
heated  by  exposing  the  glass  surface  over  the  light  for  a 
second  or  two,  and  having  ascertained,  by  pressing  its  metallic 
surface  on  the  back  of  the  hand  holding  the  tongue  depressor, 
that  it  is  not  too  hot,  it  is  entered  into  the  mouth  with  its 
reflecting  surface  looking  upwards  and  forwards,  and  ad- 
vanced in  the  oral  cavity,  avoiding  the  soft  palate  and  the 
base  of  the  tongue,  until  its  upper  edge  nearly  touches  the 
pharynx  proper.  When  the  mirror  is  in  position  the  shaft  is 
rested  against  the  corner  of  the  mouth  to  insure  stability.  If 
all  conditions  are  favorable,  the  light  well  directed,  the  pa- 
tient's throat  not  too  irritable,  and  the  rhinoscope  held  at  a 
proper  angle,  that  portion  of  the  posterior  nares  towards 
which  the  rhinoscope  reflects  the  rays  of  light  will  be  illumi- 
nated, and  will  appear  in  the  mirror. 

A  satisfactory  view  can  only  be  obtained  when  the  soft 
palate  hangs  free  from  the  pharynx.  When  the  mouth  is 
opened  for  examination,  there  is  a  tendency  on  the  part  of 
the  patient  to  breathe  through  it,  the  velum  palati  and  uvula 
in  this  case  applying  themselves  tightly  against  the  pharyn- 
geal  wall,  shutting  off  all  communication  between  the  nose 
and  the  oral  cavity.  Generally,  if  the  patient  be  directed  to 
breathe  through  his  nose,  his  efforts  will  cause  the  soft  palate 
to  fall,  bringing  the  posterior  nares  into  the  field  of  the  mirror; 
sometimes,  however,  they  will  not,  in  which  case  a  nasal  sound 
such  as  the  French  word  en  may  be  tried,  as  suggested  by 
Czermak.  If  these  means  fail,  a  ten  per  cent,  solution  of 
cocaine,  applied  with  a  brush  to  the  soft  palate,  the  pharynx 
and  the  base  of  the  tongue,  will  render  the  use  of  the  palate 
elevator  possible,  and  subdue  all  irritation. 

The  palate  elevator  is  also  useful  when  an  hypertrophied 


30  RHINOSCOPY. 

uvula  interferes  with  the  view.  The  hook  is  passed  behind 
the  palate  and  the  uvula  doubles  itself  anteriorly  between  the 
raised  sides  of  the  blade.  The  hook  is  connected  with  the 

Fig.  14. 


Author's  soft-palate  elevator. 

handle  by  means  of  a  hinge,  which  enables  it  to  be  bent  later- 
ally and  to  be  held  with  either  hand  without  interfering  with 
vision. 

THE   POSTEBIOB,   EHINOSCOPIC   IMAGE 

What  is  called  the  posterior  rhinoscopic  image  is  only  seen 
in  its  entirety,  when,  through  a  particular  fitness  of  the  parts 
a  large  mirror  can  be  passed  behind  the  soft  palate.  In 
ordinary  subjects,  however,  only  the  small  mirror  shown  in 
Fig.  12  can  be  used.  Occasionally  the  lateral  half  of  the  pos- 
terior nares  can  be  seen,  but  generally  only  portions  of  it  can 
be  brought  into  view  at  one  time.  Whatever  can  be  seen  must 
be  noted  mentally,  and  the  image  constructed  by  the  proper 
combination  of  the  parts  examined.  Unless  the  surface  of 
the  mirror  be  held  exactly  on  a  plane  with  the  parts  before 
it,  the  image  will  be  distorted  and  confusion  result  if  the 
observer  be  not  very  familiar  with  the  general  conformation 
of  the  posterior  nares.  These  difficulties  make  a  post-rhino- 
scopic  examination  a  rather  difficult  procedure,  requiring  on 
the  part  of  the  observer  not  only  a  thorough  anatomical 
conception  of  the  parts,  but  also  great  care  in  conducting  his 
manipulations. 

The  rhinoscope  being  in  position  on  either  side  of  the  uvula, 
the  first  object  to  appear  in  it,  near  its  lower  edge,  will  be  the 
profile  of  the  upper  surface  of  the  soft  palate.  Above  it,  and 


THE   POSTERIOR  RHINOSCOPIC   IMAGE.  31 

somewhat  in  the  background,  the  half  of  the  posterior  nasal 
image  will  come  into  view,  with  the  septum,  broad  above  and 
tapering  to  a  narrow  edge  as  it  approaches  the  floor,  as  internal 
boundary,  and  the  prominence  of  the  Eustachian  tube,  as  ex- 
ternal. These  are  excellent  points  of  demarcation,  being  the 
first  to  strike  the  eye  of  the  observer  by  their  yellowish  hue, 
which  contrasts  with  the  pink  of  the  surrounding  parts.  Be- 
tween them,  and  with  its  lower  border  slightly  impinged  upon 
by  the  Eustachian  prominence,  appears  one  of  the  posterior 
nares,  shaped  somewhat  like,  and  about  the  size  of  a  pigeon's 
egg,  and  surrounding  like  a  frame  the  posterior  ends  of  the 
three  turbinated  bones.  The  end  of  the  inferior  turbinated 
bone  looks  more  like  a  rounded,  pinkish-white  mass  lying  in 
the  lower  and  outer  corner  of  the  iiarium,  than  like  the  end  of 
a  surface  likened  to  a  slanting  shelf;  this  is  due  to  the  fact 
that  it  gradually  thickens  as  it  advances  posteriorly,  and  that 
its  bulging  portion  only  can  be  seen,  while  its  edge,  which  is 
almost  in  contact  with  the  floor  of  the  nose,  is  hidden  from 
view  by  the  Eustachian  prominence.  The  middle  turbinated, 
of  the  same  color,  appears  just  above  the  inferior,  a  narrow 
shadow  separating  them*  Its  outline  is  better  defined,  and 
the  interval  between  its  margin  and  the  septum  wider.  At  its 
point  of  contact  with  the  external  wall,  it  is  about  a  quarter 
of  an  inch  thick,  but  it  gradually  tapers  and  curves  down- 
ward, until  its  internal  edge  is  lost  to  view  behind  the  inferior 
turbinated.  The  superior  turbinated  is  more  difficult  to  see, 
its  position  causing  it  to  be  poorly  illuminated.  Its  color  is 
yellowish,  and  the  curve  of  its  surface  much  less  evident  than 
that  of  the  middle.  It  appears  as  if  hanging  from  the  roof 
of  the  cavity,  and  is  deeply  imbedded  in  shadows. 

If  now  the  handle  of  the  rhinoscope  be  elevated  somewhat, 
causing  the  mirror  to  incline  nearer  the  horizontal,  the  almost 
red,  dome-like  cavity  of  the  vault  of  the  pharynx  will  be 


RHINOSCOPY. 

brought  into  view,  its  glandular  character  rendering  its  sur- 
face irregular  and  furrowed. 

Elevating  the  handle  a  little  more,  the  image  will  be  com- 
pletely changed,  the  parts  posterior  to  the  anterior  portion  of 
the  vault  now  appearing  reversed.  The  wall  of  the  pharynx, 
just  above  the  mirror,  will  appear  near  its  upper  margin,  its 
smooth  dark  pink  surface  gradually  becoming  grooved  and 
indented,  until  an  irregular  profile  outline  is  reached,  made 
evident  by  a  deep  shadow  which  forms  the  background.  The 
outline  is  that  of  the  lower  edge  of  the  pharyngeal  tonsil  if  this 
is  enlarged,  or  the  bulging  produced  by  the  body  of  the  first 
vertebra,  if  it  is  not.  The  background  is  the  cavity  above, 
which  is  not  illuminated.  If  the  mirror  be  now  drawn  away 
from  the  pharynx  a  line  or  so,  the  handle  being  tilted  upward 
a  little  more,  a  good  view  of  the  vault  will  be  obtained  in  most 
cases.  When  the  palate  elevator  is  easily  tolerated  by  the 
parts  and  the  uvula  and  velum  palati  are  raised  or  retracted 
from  the  pharynx,  the  mirror  can  be  placed  in  the  middle  line, 
and  the  opening  of  the  pharyngeal  bursa,  a  deep  depression  in 
the  pharyngeal  tonsil,  distinctly  seen. 


CHAPTER  IV. 

IXSTKUMEXTS    USED    IX   CLEAXSIXG  AXD    MEDICATING    THE    NASAL 

CAVITIES. 

THIS  chapter  will  be  devoted  to  the  consideration  of  instru- 
ments used  in  cleansing  and  medicating  the  anterior  and  pos- 
terior nasal  cavities,  leaving  those  required  in  operative  or 
special  procedures  to  be  described  under  the  headings  of  the 
affections  in  which  they  are  required. 

The  Douche. — The  instrument  generally  called  the  "nasal 
douche"  is  a  cylindrical  vessel  either  made  of  glass  or  of  tin, 
of  a  capacity  of  from  one  to  two  pints  (Fig.  15).  Its  side  is 
perforated  near  the  bottom  for  the  attachment  of  a  piece  of 

Fig.  15. 


Nasal  douche  with  Author's  thermometer  attachment. 


rubber  tubing  furnished  at  its  free  end  with  a  nose  piece,  so 
shaped  as  to  close  the  nostril  like  a  stopper  when  held  firmly 
against  it.  In  order  to  regulate  the  flow  of  liquid,  a  stopcock 

3  (33) 


34  INSTRUMENTS  USED  IN  TREATING  THE  NASAL  CAVITIES. 

is  connected  with  the  small  opening  of  the  vessel,  while  an 
ordinary  bath  thermometer,  suspended  in  the  center  of  the 
instrument,  serves  to  indicate  the  temperature  of  the  fluid. 

When  in  use  the  instrument  is  filled  with  the  solution  re- 
quired, and  the  nose  piece  is  adapted  to  the  nostril.  The  head 
is  tilted  forward,  the  stopcock  turned  on,  and  the  vessel  raised 
to  a  level  with  the  forehead,  which  will  cause  the  liquid  to 
flow,  by  gravitation,  through  one  nasal  fossa  and  fill  the  pos- 
terior nasal  cavity.  Breathing  through  the  mouth  having 
caused  adaptation  of  the  soft  palate  to  the  pharynx,  the  fluid 
will  pass  out  of  the  other  nostril.  The  whole  tract  is  thus 
thoroughly  bathed,  and  cleansed  of  what  desiccated  mucus, 
pus,  etc.,  may  have  collected  there,  and  what  remains  become 
so  softened  as  to  be  easily  gotten  rid  of  subsequently. 

Some  prejudice  has  arisen  against  the  use  of  the  nasal 
douche,  through  the  fact  that  in  conjunction  with  its  employ- 
ment, inflammation  of  the  Eustachian  tubes  has  taken  place, 
followed  in  some  cases  by  the  gravest  results.  I  will  here 
state  that,  notwithstanding  the  large  number  of  cases  in 
which  I  have  prescribed  it  in  hospital  and  private  practice,  I 
have  yet  to  see  any  deleterious  effect  following  its  use.  There 
is  no  doubt,  however,  that  it  can  do  much  harm  if  prescribed 
indiscriminately  and  without  giving  the  patient  careful  direc- 
tions. Several  conditions  must  be  observed,  which,  neglected, 
make  it  a  dangerous  instrument. 

1.  A  positive  diagnosis  of  the  case  must  be  made. 

2.  The  liquid  must  not  be  colder  than  90°  F.    The  nearer  the 
temperature  of  the  blood  is  approached  the  better;  but  again, 
it  must  not  be  much  above  that,  because  the  mucous  membrane 
is  exposed  to  the  atmosphere  as  soon  as  the  application  is 
ended,  and  the  relative  difference  between  the  ordinary  heat  of 
the  nasal  cavities  and  that  of  the  air  is  increased,  producing 
the  same  effect  as  exposure  to  cold. 


THE  DOUCHE.  35 

3.  The  liquid  should  not  be  forced  through  the  nasal  cavities 
u'ith  too  much  power,  not  only  on  account  of  the  vigorous  fric- 
tion to  which  the  membrane  would  be  exposed,  but  because 
the  cavity  through  which  the  liquid  escapes  from  the  nose 
might  not  be  quite  as  large  as  that  through  which  it  enters, 
and  a  certain   amount  of   resistance  might  be   established, 
by  which  the  liquid  would  be  forced  into  the  Eustachian 
tubes  and  the  accessory  cavities.    Holding  the  vessel  with  its 
bottom  on  a  plane  with  the  forehead  suffices  to  produce  a 
stream  well  calculated  to  bathe  gently  the  nasal  passages,  and 
not  powerful  enough  to  penetrate  into  the  surrounding  cavi- 
ties, should  any  cause  of  interference  with  the  egress  of  the 
liquid  be  present. 

4.  Swallowing  should  be  carefully  avoided  ivhile  the  douche  is 
'being  used.    This   act,  inducing  temporary  dilatation  of  the 
Eustachian  tubes,  would  cause  the  fluid  to  penetrate  into 
them.    The  cases  in  which  middle  ear  troubles  were  reported 
as  being  caused  by  the  use  of  the  douche,  were  probably  due 
to  neglect  of  this  rule. 

5.  The  liquid  should  always  be  rendered  alkaline,  to  imitate,  as 
much  as  possible,  the  secretion  of  the  mucous  and  serous 
glands  in  density  and  reaction.    Bland  or  acidulous  liquids 
give  rise  to  severe  smarting,  and  cause  congestion  and  disten- 
sion of  the  mucous  membrane.     Bicarbonate  of  sodium,  bibo- 
rate  of  sodium,  and  chlorate  of  potassium,  are  the  best  agents 
for  the  purpose,  one  teaspoonful  of  either  being  thoroughly 
dissolved  in  a  pint  of  water. 

When  crusts  of  desiccated  mucus  fail  to  become  detached 
by  the  gentle  current  of  the  douche  used  anteriorly,  it  shoiild 
be  applied  posteriorly,  that  is  to  say,  by  passing  a  curved 
nozzle  connected  with  the  instrument  behind  the  soft  palate 
(see  Fig.  16),  and  directing  the  stream  of  liquid  towards  the 
vault  and  posterior  nares.  But  here  again,  certain  precautions 


36  INSTRUMENTS  USED  IN  TREATING  THE  NASAL  CAVITIES. 

are  necessary  in  addition  to  those  enumerated  for  the  applica- 
tion of  the  douche  anteriorly. 

The  perviomness  of  both  anterior  cavities  should  be  ascertained 
and  the  quantity  of  liquid  thrown  in  limited  to  the  amount 
that  can  readily  pass  out.  This  can  be  regulated  by  the  stop- 
cock. Were  this  neglected,  and  some  condition  or  other  induc- 
ing complete  or  partial  stenosis  be  present,  the  fluid  would 
regurgitate  into  the  mouth  and  perhaps  into  the  larynx. 

The  head  should  be  tilted  forward  as  much  as  possible,  so  that 
in  case  any  fluid  should  perchance  regurgitate,  it  could  find  an 
easy  egress  through  the  mouth  without  endangering  the  larynx. 

While  in  charge  of  Dr.  Cohen's  practice  some  years  ago,  I 
had  occasion  to  use,  in  connection  with  a  douching  apparatus, 
a  neat  little  curved  nozzle  devised  by  him,  which  for  simplicity 
and  usefulness  is  surpassed  by  none.  It  consists  merely  of  a 
piece  of  glass  tubing  eight  inches  long,  with  one  end  flattened 
and  bent,  as  shown  in  Fig.  16.  By  adjusting  the  straight  end 
to  the  rubber  tube  of  the  douche,  a  convenient  handle  is 
formed,  and  the  flat  fan-shaped  tip  can  be  easily  passed 
behind  the  soft  palate  and  held  there  by  the  patient. 

I  have  used  one  of  these  tubes  ever  since.  The  stream 
formed  is  also  fan-shaped,  and  by  alternately  raising  and 
lowering  the  end  engaged  in  the  rubber  tubing,  the  fluid  will 
bathe  the  whole  surface  of  the  cavities  and  propel  before  it 
what  substances  may  have  become  detached.  The  patient 
readily  learns  how  to  manipulate  it,  although  occasionally 
some  cases  are  met  with  in  which  an  hypersensitive  pharynx 
seems  to  preclude  its  employment.  After  a  few  efforts,  how- 
ever, the  parts  will  generally  become  more  tolerant,  not  only 
rendering  posterior  douching  possible,  but  also  greatly  facili- 
tating subsequent  rhinoscopic  examinations  by  accustoming 
the  parts  to  manipulation. 

Occasionally  a  more  forcible  current  is  required  to  remove 


THE  DOUCHE. 


37 


desiccated  crusts  of  mucopus  which  resist  the  gentle  pressure 
of  the  douche,  even  when  this  pressure  is  increased  by  raising 
the  vessel  as  high  as  the  length  of  the  rubber  tube  will  permit. 
A  very  effective  instrument  for  that  purpose  is  that  known  as 
"Hall's  syringe"  (Fig.  16),  a  glass  jar  surmounted  by  a  bulb, 

Fig.  16. 


Hall's  continuous-stream  syringe,  with  Cohen's  post-nasal  tube  attached. 

with  a  valve  between  them.  When  this  bulb  is  pressed  upon, 
the  air  contained  in  the  jar  is  compressed,  and  the  liquid  is 
forced  up  a  perpendicular  glass  tube,  which  connects  externally 
with  a  piece  of  rubber  tubing  such  as  that  attached  to  the 
douching  apparatus.  A  continuous  stream  is  thus  obtained, 
the  force  and  rapidity  of  which  can  be  nicely  regulated  by 
the  amount  of  air  forced  into  the  vessel. 

In  the  many  cases  of  nasal  affections  in  which  the  douche 
is  contra-indicated,  a  spray-producing  arrangement  will  best 
suit  for  cleansing  purposes ;  but  the  spray  must  be  somewhat 
coarse.  Sass'  tubes,  shown  in  Fig.  17,  answer  the  purpose 
perfectly,  and  can  be  used  anteriorly  or  posteriorly.  They  are 
made  of  glass  and  of  hard  rubber,  and  are  simple  in  construc- 
tion. Each  instrument  consists  of  two  tubes,  one  superposed 
on  the  other;  the  lower  one  dips  into  the  solution  and  the 
other  is  connected  with  a  double  bulb  arrangement,  as  shown 


<J 


465  i  5 


38 


INSTRUMENTS  USED  IN  THEATING  TEE  XASAL  CAVITIES. 


in  Fig.  17.  Their  free  ends  are  pointed  and  meet  in  such  a 
manner  that  when  air  is  forced  through  one  tube,  that  in  the 
other  is  exhausted,  and  the  liquid  takes  its  place  by  atmos- 
pheric pressure.  When  the  liquid  appears  at  the  opening,  the 


Fig.  17. 


Sass'  spray  tubes. 

current  of  air  from  the  other  tube  breaks  it  up  into  spray  or 
atoms  (hence  "atomizer")  and  carries  it  along  in  that  condi- 
tion in  the  direction  it  follows. 

A  single  bulb  can  be  used,  but  the  current,  following  the 
motion  of  the  hand,  is  intermittent,  which  is  not  the  case  with 
the  double  bulb  arrangement,  the  middle  one  serving  to  store 
the  air  and  keep  up  a  continuous  current  by  its  elasticity. 

In  special  practice,  however,  the  rubber  bulb  apparatus  is 
rather  inconvenient  and  tiresome  when  handled  frequently. 
A  compressed  air  pump  of  some  kind  is  much  more  desirable. 
Among  other  advantages,  it  gives  the  freedom  of  one  hand, 
with  which  the  tongue  depressor  or  the  nostril  dilator  can  be 
manipulated.  The  most  convenient  instrument  for  the  purpose 
is  Burgess'  air  compressor  (Fig.  18).  It  consists  of  a  metallic 


ATOMIZERS.  39 

cylinder,  into  which  ah-  is  forced  by  means  of  a  little  pump, 
worked  by  the  foot.  A  pressure  gauge  is  connected  with  it, 
which  enables  the  operator  to  note  and  regulate  the  degree  of 
pressure.  The  air  reaches  the  atomizer  through  a  rubber  tube 
attached  to  a  stopcock,  which  is  connected  with  the  cylinder 
near  its  upper  edge. 

Fig.  18. 


Burgess'  air  compressor. 

The  manipulation  of  the  atomizer,  although  easy,  should  be 
attended  with  great  care.  If  used  carelessly,  but  a  small 
quantity  of  the  spray  penetrates  into  the  nasal  cavities,  the 
greater  part  of  it  condensing  on  the  parts  nearest  the  tip  of  the 
instrument.  For  the  anterior  nares  the  tip  should  be  intro- 
duced a  short  distance,  and  the  direction  of  the  spray  varied 
by  raising  or  lowering  the  vessel  containing  the  liquid,  the 
anterior  edge  of  the  nasal  floor  acting  as  resting  point  and 
pivot.  For  the  posterior  nares,  the  two  hands  being  required, 
if  a  rubber  bulb  is  used,  its  manipulation  can  be  entrusted  to 
the  patient.  The  tongue  should  be  depressed  and  the  tip  of 
the  atomizer  held  behind  the  uvula.  Frequently,  as  soon  as 


40  INSTRUMENTS  USED  IN  TKEATING  THE  NASAL  CAVITIES 

the  spray  is  started  the  soft  palate  is  drawn  upward  against  the 
pharynx.  The  palate  elevator  (Fig.  14)  might  then  be  used, 
or  the  patient  be  directed  to  close  his  mouth  around  the 
tubes.  Being  forced  to  breathe  through  the  nose,  the  soft 
palate  is  relaxed,  leaving  ample  space  behind  for  the  passage 
of  the  spray.  The  head  should  be  tilted  forward,  not  only  to 
facilitate  the  egress  of  the  condensed  liquid  through  the  ante- 
rior nares,  but  also  to  increase  the  size  of  the  isthmus.  The 
atomizer  should  be  held  in  the  right  hand,  with  the  rubber 
tube  resting  between  the  bottle  and  the  thumb.  The  rubber 
bulb  being  then  compressed,  or  the  stopcock  of  the  air-com- 
pressor turned  on,  the  air  will  fill  that  portion  of  the  rubber 
tube  between  the  bulbs  or  compressor  and  the  thumb.  The 
tip  of  the  spray  tube  being  then  properly  located,  the  thumb 
is  raised,  giving  way  to  the  passage  of  air.  When  it  is  de- 
sirable to  stop  the  spraying,  pressure  is  again  exerted  on  the 
rubber  tube  and  the  current  arrested. 

In  some  cases,  when,  through  malformation  or  the  presence 
of  anterior  or  posterior  hypertrophies,  polypi,  etc.,  the  spray 
used  in  the  ordinary  way  cannot  reach  certain  parts  of  the 
cavities,  it  is  necessary  to  introduce  the  tube  much  beyond 
the  usual  depth.  Fig.  19  represents  an  instrument  which  I 
have  used  for  a  number  of  years  to  great  advantage.  It  can 
be  used  with  rubber  bulbs  or  the  air-compressor.  Unlike  the 
other  atomizers,  it  has  only  one  tube,  the  air  being  forced  up 
through  it  and  broken  up  into  spray  while  passing  through 
the  tip-hole,  which  is  very  small,  or  through  a  series  of  minute 
holes  which  penetrate  its  upper  surface  for  perpendicular  irri- 
gation, as  suggested  by  Dr.  Bumbold,  of  St.  Louis. 

Occasionally,  a  comparatively  straight  and  wide  inferior 
meatus  renders  it  possible  to  introduce  the  cud  of  the  tube  as 
far  as  the  posterior  nares,  and  to  spray  the  pharyngeal  tonsil 
directly.  "When  practicable  it  should  always  be  done,  as  the 


ATOMIZEKS. 


41 


crypts  and  lacunae  are  better  cleansed  of  their  secretions  by 
direct  sprays,  than  when  these  are  directed  from  below. 


Fig.  19. 


^ — r.. 


Snowden's  atomizer. 


The  instruments  used  for  cleansing  the  anterior  and  poste- 
rior nasal  cavities  can  also  be  employed  to  apply  medicated 
liquids,  but  with  the  atomizers,  care  must  be  taken  that  the 


4:2        INSTRUMENTS   USED   IN   TREATING  THE   NASAL   CAVITIES. 

solution  used  be  perfectly  free  of  all  sediments  or  solid  par- 
ticles that  might  render  the  tubes  impervious  by  closing  their 
apertures.  Chemical  action  on  metallic  tubes  produces  the 
same  effect  when  strong  solutions  are  employed. 

For  the  application  of  solutions  in  small  quantities,  we  have 
the  brush,  the  sponge,  and  the  cotton  pledget. 

I  have  long  ago  abandoned  the  use  of  the  brush.  Besides 
being  inconvenient  and  uncleanly,  it  does  not  fulfill  its  object. 
The  sponge  is  not  much  better,  presenting  the  same  objec- 
tions, besides  that  of  being  difficult  to  hold  in  the  grasp  of 
an  instrument.  By  far  the  most  convenient  in  my  opinion  is 
the  cotton  pledget,  its  value  being  much  enhanced  by  the 
excellent  absorbent  cottons  now  at  our  disposal.  A  small 
piece  can  be  used  for  each  application,  then  burnt. 

For  applications  to  the  anterior  nares  the  delicate  probe 
shown  in  Fig.  20  is  much  used  as  a  cotton  carrier. 

Fig.  20. 


Harrison  Allen's  cotton  carrier. 


About  one-half  inch  of  the  end  of  the  instrument  being 
roughened,  a  thin  film  of  cotton  is  merely  wrapped  around  it. 
It  adheres  well,  and  can  be  made  to  form  so  little  volume 
around  the  end  of  the  probe  that  it  can  be  introduced  in  any 
part  of  the  cavity. 


Fig.  21. 


Swift's  cotton  and  bougie  carrier. 


I  have  been  using  of  late,  a  neat  little  instrument  shown  in 
Fig.  21  which  serves  very  conveniently  as  a  probe  and  as  a 
cotton  holder,  and  is  especially  adapted  for  the  introduction 


COTTON   CARRIERS.  43 

of  medicated  bougies.  A  threaded  pit  at  the  rounded  ex- 
tremity enables  the  operator  to  introduce  the  end  of  a  soft 
copper  pin,  which  also  becomes  threaded  and  is  held  firmly 
in  situ.  The  pin  serves  for  the  cotton  or  for  the  bougie,  and 
can  be  easily  taken  off  and  thrown  away  with  either  after 
being  used. 

For  posterior  nasal  applications,  the  instrument  shown  in 
Fig.  22,  a  modification  of  Cohen's  laryngeal  forceps  serves 
me  better  than  any.  It  is  simple  in  construction,  and  its 

Fig  22. 


Author's  modification  of  Cohen's  laryngeal  forceps. 


method  of  locking  makes  it  perfectly  secure,  while  its  curve 
renders  it  available  for  applications  to  the  posterior  nares  or 
any  part  of  the  pharyngeal  vault.  Its  claws  are  armed  with 


Fig.  23. 


Position  while  in  the  mouth. 


teeth  which  penetrate  through  the  cotton  pledget,  holding  it 
with  absolute  security.    The  instrument  should  be  held  as 


44  INSTRUMENTS  USED  IN  TREATING  THE  NASAL  CAVITIES. 

shown  in  Fig.  23,  i.  e.,  like  a  pen.  To  introduce  it  the  tongue 
should  be  depressed,  and  the  instrument  being  held  hori- 
zontally, its  point  is  advanced  in  the  mouth  until  almost 
against  the  pharynx.  When  under  the  isthmus  a  slight 
turn  of  the  hand  will  cause  the  tip  to  turn  upward  and  enter 
the  posterior  nasal  cavity.  Here  its  position  can  be  modified 
so  as  to  touch  the  desired  spot  by  altering  the  relative  posi- 
tion of  the  body  of  the  instrument. 

Fig.  24. 


The  instrument  turned  upward  behind  the  soft  palate. 

At  times  the  soft  palate  tightly  closes  the  isthmus,  render- 
ing the  introduction  of  the  forceps  impossible.  The  patient 
should  be  requested  to  breathe  through  his  nose,  a  very  diffi- 
cult matter  to  some  persons;  but  the  mere  effort  generally 
succeeds  in  detaching  the  soft  palate  from  the  pharynx  only 
for  an  instant,  of  which  advantage  must  be  taken,  and  the  tip 
passed  up  behind  it.  If  this  does  not  succeed  the  French 
word  en  may  be  tried.  If  this  also  fails,  the  forceps  should  be 
left  in  situ  and  the  mouth  closed  on  it.  The  patient  being 
then  directed  to  take  a  deep  breath,  the  soft  palate  will  of 
necessity  leave  the  pharynx,  and  allow  the  tip .  of  the  instru- 
ment to  be  introduced  by  rotating  the  latter  on  its  axis.  The 
same  difficulties  are  sometimes  encountered  in  extracting  the 


INSUFFLATORS.  45 

forceps,  the  soft  palate  grasping  the  instrument  tightly.  The 
same  means  as  for  the  introduction  can  be  resorted  to,  great 
care  being  taken  not  to  extricate  the  instrument  roughly. 
When  possible,  the  rhinoscope  should  be  used  to  guide  the 
application,  the  tongue  depressor  being  held  by  the  patient. 

It  might  not  be  amiss  to  say  a  few  words  in  reference  to  the 
manner  in  which  the  cotton  pledget  should  be  folded  before 
engaging  it  in  the  instrument.  A  piece  about  an  inch  long 
and  half  an  inch  wide,  is  spread  out  between  the  fingers,  then 
doubled  up  twice.  It  is  then  folded  crosswise  once  and 
engaged  between  the  teeth  of  the  forceps  longitudinally.  If 
the  application  is  to  be  made  to  a  small  spot,  it  must  be  folded 
tightly;  if  on  the  contrary,  a  large  surface  is  to  be  covered,  a 
less  dense  pledget  will  absorb  more  of  the  liquid.  In  using 
strong  solutions,  care  should  be  taken  to  fold  the  cotton 
tightly,  lest  muscular  contraction  during  the  application 
should  cause  the  fluid  to  flow  along  the  pharynx  and  irritate 
adjacent  parts. 

For  the  application  of  powders  to  the  nasal  cavities,  the 
instrument  shown  in  Fig.  25  is  the  most  convenient.  It  con- 
sists of  two  hard  rubber  tubes  fitting  into  each  other  and 
furnished  with  a  rubber  ball.  The  end  piece  is  either  bent  at 
its  extremity,  to  adapt  it  for  carrying  the  powder  into  the 
posterior  nares  or  when  turned  downward  into  the  larynx,  or 
straight,  for  insufflations  into  the  anterior  nares.  The  ex- 
tremity fitting  in  the  piece  connected  with  the  rubber  ball  is 
shaped  like  a  scoop,  with  which  the  powder  is  taken  up.  The 
scoop  being  fitted  into  the  cavity  of  the  other  tube,  the  instru- 
ment is  ready  for  use.  It  is  then  held,  as  shown  in  the  cut, 
by  resting  the  thumb  behind  the  rubber  bulb,  and  the  middle 
and  index  fingers  in  front  of  it  with  the  tube  between  them. 
The  insufflator  being  placed  in  the  desired  position,  a  sudden 
pressure  on  the  bulb  will  drive  the  air  through  the  tube,  and 


46       INSTRUMENTS   USED   IN  TREATING  THE  NASAL   CAVITIES, 

carrying  the  powder  before  it,  deposit  it  upon  the  part  to  be 
medicated.  For  the  anterior  nares  the  straight  end-piece 
should  be  used  and  introduced  about  one-half  inch.  The 
inspiratory  act  can  be  taken  advantage  of  if  the  whole  nasal 
tract  is  to  be  covered  with  the  powder,  this  of  course  only 
applying  to  the  use  of  non-irritating  substances.  If  the 
application  is  to  be  limited  to  the  anterior  portion  of  the  nose, 
the  patient  should  refrain  from  breathing  during  the  insuffla- 
tion. For  the  posterior  nares  the  manipulation  is  the  same 

Fig.  25. 


The  scoop  insufflator. 

as  that  for  the  cotton  forceps,  the  same  rules  holding  good 
when  the  velum  palati  interferes  with  the  application. 

The  insufflator  shown  in  Fig.  26  was  devised  by  Dr.  A. 
H.  Smith,  of  New  York.  Its  construction  is  much  like  that 
of  the  single  hand  ball  atomizer,  the  tubes  being  larger. 
When  the  air  bulb  is  pressed,  the  powder  is  stirred  up  and  a 
small  portion  of  it  is  forced  out  through  the  mouth-piece  and 
deposited  on  the  spot  to  be  medicated,  in  the  form  of  a  fine 
evenly  diffused  film.  This  is  a  great  advantage  possessed  by 
no  other  instrument  of  the  kind.  Unfortunately  it  requires 


INSUFFLATOES. 


47 


the  use  of  both  hands,  and  the  amount  of  powder  cannot  be 
regulated.  By  connecting  it  with  the  air-compressor,  shown 
in  Fig.  18,  the  first  disadvantage  can  be  avoided,  while  the 
second  can  be  much  reduced  by  using  substances  in  which 
exact  dosage  is  not  of  prime  importance,  such  as  iodoform, 
boracic  acid,  tannin,  etc. 

The  manner  in  which  an  insufflator  is  used  influences  greatly 
the  value  of  the  application.  Merely  blowing  its  contents  into 
the  cavity  will  naturally  cause  the  powder  to  be  deposited 
over  a  limited  surface,  but  if  instead  of  one  puff,  this  be 

Fig.  .,0. 


Dr.  A.  H.  Smith's  insufflator. 

divided  into  three  or  four  light  ones,  each  time  altering  the 
direction  of  the  instrument,  the  area  covered  will  be  much 
increased,  and  comprise  the  entire  surface  of  the  cavity 
treated  if  the  manipulation  is  carefully  conducted. 

When  insufflators  are  to  be  used  by  the  patient,  the  little 
instrument  shown  in  Fig.  27  will  be  found  very  effective.  It 
consists  of  a  piece  of  glass  tubing  two  inches  long  slightly 
bent  and  expanded  in  the  middle,  with  the  convexity  flattened 
below  and  roughened.  The  upper  surface  has  an  opening  for 
the  insertion  of  the  powder.  A  piece  of  rubber  tubing,  furn- 


48        INSTRUMENTS   USED   IN   TEEATING   THE   NASAL   CAVITIES. 

islied  with  a  glass  mouth-piece,  is  attached  to  it,  by  means  of 
which  the  patient  can  insufflate  into  his  own  nose ;  if  a  child, 
the  mouth-piece  can  be  used  by  the  mother  or  by  an  attend- 
ant. The  powder  having  been  placed  in  the  glass  cup,  the 
latter  is  held  with  the  end  of  the  index  finger  on  the  open- 
ing, thus  closing  it  up,  and  the  thumb  resting  on  the  rough- 
ened surface  below.  The  tip  being  then  passed  into  the 
nostril  and  the  mouth-piece  inserted  into  the  mouth,  two  or 
three  light  puffs  will  propel  the  powder  and  distribute  it  over 
the  mucous  lining. 

The  same  instrument  can  also  be  used  with  advantage  to 
insufflate  the  fumes  of  volatile  substances.    A  piece  of  ab- 

Fig.  27. 


--C---" 


Author's  nasal  insufflator  for  the  use  of  patients. 

sorbent  cotton  the  size  of  a  small  chestnut  is  introduced 
through  the  aperture  on  the  upper  surface  and  a  few  drops  of 
the  agent  used  are  poured  on  it.  The  aperture  is  then  closed 
with  a  stopper,  and  the  instrument  is  manipulated  as  for 
powders,  the  insufflations  being  prolonged  and  repeated. 

Applied  in  this  way,  the  emanations  of  volatile  drugs  are 
distributed  throughout  the  nasal  fossae  in  a  more  effective 
manner  than  when  inhaled,  the  respiratory  current  not  inter- 
fering with  the  dissemination  of  the  vapor.  The  act  of  blow- 
ing through  the  mouth  necessitating  close  adaptation  of  the 
soft  palate  to  the  wall  of  the  pharynx,  the  isthmus  is  tightly 
closed,  and  the  nasal  cavities  are  completely  isolated.  They 


INHALERS.  49 

can  thus  be  filled  with  the  fumes  of  the  drug  used,  and  the 
contact  of  the  latter  with  the  membrane  can  be  prolonged 
for  a  considerable  time  by  continuing  to  breathe  through  the 
mouth.  An  advantage  accompanying  these  auto-insufflations 
is  that  the  current  of  air  acting  as  a  propelling  agent  is  well 
prepared  to  meet  the  inflamed  surfaces,  being  supplied  with 
heat  and  moisture  and  absolutely  free  of  extraneous  particles. 

In  the  treatment  of  catarrhal  affections  of  the  Eustachian 
tubes,  I  have  found  it  very  effective.  By  closing  the  nostrils 
tightly  with  the  fingers,  the  tip  of  the  instrument  being  in- 
serted on  either  side,  inflation  of  the  tubes  can  not  only  be 
performed,  but  these  can  be  kept  open  and  exposed  to  the 
effects  of  the  medicinal  vapor  for  a  considerable  time  at  each 
sitting  by  continuing  the  expiratory  effort  acting  as  mechani- 
cal force,  as  long  as  possible,  i.  e.,  until  the  breath  is  ex- 
hausted. This  is  repeated  several  times  in  succession.  Re- 
newed two  or  three  times  daily,  this  procedure  leads  to  a 
much  more  rapid  recovery  than  by  the  methods  usually  em- 
ployed. 

Inhalations  of  medicated  steam  are  sometimes  very  useful 
in  the  treatment  of  nasal  affections.  The  inhaler  shown  in 
Fig.  28  combines  all  the  advantages  of  instruments  of  that 
kind,  and  introduces  a  simple  device  by  means  of  which  the 
medicated  steam  can  be  made  to  enter  the  Eustachian  tubes 
and  the  accessory  cavities.  The  cut  represents  the  instrument 
as  it  would  appear  were  it  exactly  divided  perpendicularly. 

It  is  made  of  tin  plate,  and  of  the  capacity  of  one  pint;  a 
is  a  tube  for  the  entrance  of  air ;  &,  an  opening  of  the  same 
diameter  as  that  of  the  tube  «,  for  the  egress  of  the  air  along 
with  the  steam;  this  opening  is  covered  externally  by  a  valve, 
which  is  raised  by  the  current  of  air  and  steam  as  these  are 
inhaled,  and  closed  by  the  exhaled  current ;  c ,  is  another  open- 
ing also  covered  by  a  valve,  which  is  opened  in  expiration  and 


50       INSTRUMENTS   USED   IN   TREATING  THE  NASAL   CAVITIES. 

closed  in  inspiration.  When  an  inhalation  is  taken,  the  air 
rushes  in  at  «,  passes  through  the  medicated  liquid,  and  out 
along  with  steam  through  <?,  raising  the  large  valve.  In  exha- 
lation, the  air  is  blown  back  into  the  mouth-piece,  and  out  of 
the  upper  and  smaller  opening,  c,  into  the  surrounding  atrnos- 


Author's  inhaler. 


phere.    A  thermometer  passing  through  the  stopper  indicates 
the  temperature  of  the  steam. 

For  the  treatment  of  the  nasal  passages,  an  attachment  is 
adapted  consisting  of  a  stopper,  e,  fitting  exactly  into  the 
mouth-piece,  and  through  which  a  rubber  tube  is  passed. 
This  tube  is  furnished  at  its  distal  end  with  a  perforated  glass 
ball,  f,  which,  when  applied  to  either  nostril,  closes  it  hermeti- 
cally. A  few  shallow  breaths  are  sufficient  to  fill  the  nasal 
cavities  with  the  medicated  atmosphere. 


INHALEKS.  51 

When  the  Eustachian  tubes  or  the  accessory  cavities  are 
implicated  in  the  affection,  the  medicated  steam  can  be  caused 
to  penetrate  into  them  by  reducing  the  size  of  the  expiratory 
opening.  For  this  purpose  the  latter  is  furnished  with  a  "  re- 
gulator" by  means  of  which  its  diameter  can  be  increased  or 
diminished  at  will.  The  expiratory  effort  meeting  with  resist- 
ance, forces  the  inhaled  medicated  atmosphere  into  them. 


CHAPTER  Y. 

THERAPEUTICS   OF  THE  NASAL   CAVITIES. 

THE  first  essential  in  the  treatment  of  the  nasal  cavities  is 
cleanliness.  Its  importance  is  such  that  its  proper  observance 
is  sometimes  sufficient  to  bring  about  a  cure  without  the  as- 
sistance of  remedies.  This  is  especially  the  case  when  the 
inflammatory  process  is  kept  up  by  constant  exposure  to  an 
atmosphere  loaded  with  extraneous  substances  in  such  quan- 
tity as  to  overwhelm  the  physiological  functions  of  the  cilise  of 
the  ciliated  epithelium,  and  interfere  with  the  action  of  the 
glands.  Generally,  however,  it  only  forms  a  part  of  the  treat- 
ment. When  the  patient  presents  himself,  his  trouble,  in  the 
great  majority  of  cases,  is  of  long  duration,  and  inflammatory 
changes  have  already  taken  place,  giving  rise  to  hypertrophies, 
superficial  or  deep  ulcerations,  etc.  The  former,  by  inter- 
fering with  the  discharge  of  the  secretions,  cause  their  accu- 
mulation in  the  recesses  of  the  cavities,  where,  by  the  evapo- 
ration of  their  watery  constituents,  they  become  converted 
into  fetid  crusts.  The  purulent  discharges  and  scabs  of  the 
ulcerative  variety,  through  their  irritating  character,  are  a 
constant  menace  to  the  surrounding  portions,  taint  the 
patient's  breath,  and  prevent  the  application  of  medicines  to 
the  ulcerated  spots. 

The  instruments  for  cleansing  the  nasal  cavities  have  been 
described,  but  great  circumspection  must  be  used  in  choosing 
the  proper  one  and  the  solution  to  be  employed.  It  stands  to 
reason  that  if  we  have  an  inflammatory  process  giving  rise  to 
hypertrophic  changes,  a  comparatively  powerful  stream  such  as 
that  of  the  douche  will  but  stimulate  the  morbid  process,  while 
(52) 


CLEANSING   SOLUTIONS.  53 

this  stimulation  will  be  the  very  desideratum  in  the  opposite 
condition,  that  of  atrophy.  In  the  former,  then,  the  atomizer 
is  indicated,  the  spray  possessing  no  perceptible  mechanical 
force  to  irritate  the  surface  to  which  it  is  applied.  It  merely 
softens  the  obnoxious  substances,  and  these  are  subsequently 
blown  out  by  the  patient.  For  this  purpose  we  require  an 
atomizer  which  will  throw  a  rather  coarse  spray,  Sass'  for 
instance,  so  that  sufficient  liquid  to  bathe  the  parts  thoroughly 
be  thrown  into  the  cavities.  When  an  atomizer  cannot  be  ob- 
tained, the  solution  can  be  drawn  up  from  a  tumbler  through 
the  nose  and  allowed  to  run  out  of  the  mouth,  or  it  can  be 
snuffed  up  from  the  palm  of  the  hand. 

The  selection  of  the  solution  to  be  used  should  also  be 
guided  by  the  nature  of  the  affection.  Where  there  is  a  pro- 
fuse mucoid  discharge,  dependent  simply  upon  the  relaxation 
of  the  membrane,  its  mere  mixture  with  an  alkaline  liquid  will 
be  sufficient  to  cause  its  dislodgment ;  but  if  this  discharge  is 
of  a  muco-purulent  character,  forming  crusts  in  the  sinuosities 
of  the  fossae,  a  solvent  will  greatly  facilitate  the  separation  of 
these  crusts  from  the  walls  by  softening  their  edges  and  pene- 
trating underneath. 

Experiments  have  shown  me  that  the  following  agents  have 
relative  solvent  properties  corresponding  with  their  position 
in  the  list,  the  solutions  cited  representing  the  proper  strengths 
for  nasal  irrigations : — 

Aqua  Colds  (pure).  Slightly  astringent  and  styptic,  but  not 
irritating. 

Sodii  Bicarbonas,  gr.  iv,  to  water  Ij.  Emollient.  Facilitates 
resolution  of  ulcerated  surfaces. 

Sodii  Biboras,  gr.  iv,  to  water  Ij.  Antiseptic  and  slightly 
stimulating. 

Ammonii  Cliloridum,  gr.  v,  to  water  sj.  Slightly  stimu- 
lating, especially  to  glands. 


04  THERAPEUTICS    OF    THE    NASAL    CAVITIES. 

Sodii  Chloridum,  gr.  iv,  to  water  !j.  Mild  stimulant  and 
alterative. 

Potassii  Bromidum,  gr.  xv,  to  water  3j.  Sedative  and  emol- 
lient. Induces  slight  anesthesia  of  membrane. 

As  noted  under  each  heading,  the  agents  named  possess 
secondary  properties  which  should  be  taken  advantage  of 
according  to  indications.  In  uncomplicated  chronic  conges- 
tions of  the  nasal  membrane,  for  instance,  mild  stimulation  is 
of  benefit ;  a  solution  of  chloride  of  ammonium,  while  acting 
as  cleansing  agent,  would  consequently  assist  the  direct  medi- 
cinal treatment.  Again,  when  hypertrophic  changes  have 
taken  place,  and  stimulation  is  contra-indicated,  a  spray  of 
bicarbonate  of  sodium  would  suit  best,  on  account  of  its  non- 
irritating  character. 

In  cases  in  which  the  discharges  are  offensive,  or  when 
necrosis  is  present  and  disinfectants  are  required,  these  may 
either  be  used  separately  or  in  conjunction  with  the  cleansing 
solutions.  They  all  possess  either  stimulating  or  astringent 
properties,  both  of  which  are  of  advantage  in  the  conditions 
giving  rise  to  fetid  discharges.  When  the  fetor  is  not  great, 
the  biborate  of  sodium  solution  generally  suffices,  but  if  ex- 
cessive, any  of  the  following  can  be  used  with  advantage : 

Potassii  Permanganas,  gr.  j-water  §j. 

Sodii  Salicylas,  gr.  v-water  i  j. 

Acidum  Carbolicum,  gr.  j-water  Ij. 

Phenol- Sodique,  n^xv-water  §j. 

MEDICATION. 

The  drugs  used  in  the  medicinal  treatment  of  nasal  affec- 
tions may  be  classified  according  to  their  action  on  the  mucous 
membrane,  as  Astringents,  Stimulants,  Alteratives,  Sedatives, 
Protectives,  and  Escharotics. 


MEDICATION  OF  THE  NASAL   CAVITIES.  55 

ASTRINGENTS. 

The  action  of  astringents  on  the  mucous  membrane,  when 
applied  locally,  is  to  induce  contraction  of  the  elements  enter- 
ing into  its  composition.  It  was  formerly  thought  that  they 
acted  through  their  property  of  coagulating  the  albumen  con- 
tained in  its  layers  and  in  the  blood-vessels,  but  the  fact  that 
their  effect  is  only  transitory,  indicates  that  this  cannot  be 
the  case.  They  form  an  albuminate  with  the  albumen  enter- 
ing into  the  composition  of  the  mucus  covering  the  surface 
of  the  membrane,  and  if  there  is  any  excess,  it  penetrates 
through  the  surface,  combining  with  and  condensing  the  tis- 
sues beneath,  and  constringing  the  blood-vessels.  Their  power 
of  coagulation  is  probably  checked  in  the  latter  through  the 
presence  of  the  alkaline  carbonates  which  are  present  in  the 
blood.  If  the  applications  are  repeated  frequently  and  for 
some  time,  their  constringing  action  on  the  vessels  gradually 
diminishes  the  blood  supply  by  lessening  their  calibre.  The 
relaxation  of  the  capillaries  giving  rise  to  over-secretion  is 
antagonized,  and  dryness  follows  if  the  applications  are  con- 
tinued beyond  a  certain  limit.  When  chronic  congestion  has 
induced  the  formation  of  new  elements,  cellular  tissue,  vessels, 
etc,  in  the  membrane  proper,  astringents  cause  their  absorp- 
tion through  the  interference  with  nutrition  which  their  con- 
stringing  effect  on  the  vessels  induces,  and  by  the  mechanical 
pressure  their  condensing  action  gives  rise  to;  but  this  absorp- 
tion can  only  take  place  when  the  elements  are  of  recent  formation, 
that  is  to  say,  ivhen  they  are  not  firmly  organized. 

Their  action  on  the  membrane  varies  with  the  strength  of 
the  solution  used.  Very  weak  solutions  are  either  inert  or  act 
as  tonics  on  the  previously-cleansed  membrane ;  moderate 
solutions  are  astringent,  and  strong  solutions  are  irritating, 
according  to  the  drug  used.  The  different  effects  obtained 
with  the  different  degrees  of  strength -are  of  the  greatest  im- 


56  THERAPEUTICS    OF   THE   NASAL,    CAVITIES. 

portance,  and  the  success  of  the  treatment  depends  on  their 
proper  recognition. 

In  my  opinion,  the  solutions  generally  recommended  are  too 
strong,  and  since  I  have  somewhat  reduced  them  for  my  own 
use  I  have  obtained  better  results.  Again,  a  pure  astringent 
is  hardly  to  be  found,  all  possessing,  in  conjunction  with  their 
power  of  astringency,  sedative,  stimulating,  or  antiseptic 
properties.  These  properties  should  be  taken  in  consideration 
when  using  them,  choice  being  given  to  the  astringent  possess- 
ing secondary  qualities  beneficial  in  the  case. 

The  following  list  embraces  those  astringent  solutions  which 
I  have  found  most  effective  in  nasal  affections,  with  an  outline 
of  their  secondary  properties : — 

Argenti  Nitras,  gr.  v  in  water  5j. — Slightly  stimulating  in 
weak  (gr.  iij-v)  solutions,  and  sedative  in  strong  (gr.  Ix-cxx) 
solutions  on  account  of  their  powerful  constringing  action  on 
the  blood-vessels.  Induces  healthy  changes  in  indolent  ulcera- 
tion.  Indicated  when  there  are  ulceratioiis.  Contra-indicated 
in  hypertrophy. 

Plumbi  Acetas,  gr.  v-lj.< — Sedative  by  contracting  blood- 
vessels powerfully.  Indicated  in  acute  and  sub-acute  catarrhal 
conditions. 

Zinci  Sulphas,  gr.  v-ij. — Slightly  stimulating.  Hardens  sur- 
face of  membrane ;  checks  excessive  discharges  of  mucus. 
Indicated  in  relaxed  conditions  of  membrane  due  to  continued 
irritation  by  inhaling  dust,  smoke,  etc. 

Zinci  Chloridum,  gr  iij-5j. — Stimulating  and  antiseptic. 
Penetrates  deeper  into  the  membrane  on  account  of  its  higher 
diffusion-power.  Indicated  in  same  conditions  as  the  above 
when  a  stronger  astringent  effect  is  required,  and  when  the 
discharges  assume  a  purulent  character. 

Cupri  Sulphas,  gr.  v-Ij.— Somewhat  stimulating  and  disin- 
fectant. Indicated  in  chronic  catarrhal  conditions,  with  muco- 
purulent  discharges  accompanied  by  fetor. 


ASTRINGENTS.  57 

Alumen,  gr.  v-3j. — Contracts  blood-vessels,  depressing  vital 
action  of  ulcerations  and  checking  mucoid  and  purulent  dis- 
charges. Indicated  in  relaxed  membrane  with  engorged  capil- 
laries. Styptic. 

Acidum  Tanmcitm,  gr.  viij-lj. — Powerful  astringent  and 
styptic.  Affects  the  whole  substance  of  the  membrane.  Bene- 
ficial in  all  chronic  conditions  excepting  atrophy. 

The  albuminate  formed  with  the  mucus  generally  assumes 
the  form  of  a  thin  pellicle,  which  protects  the  membrane  for  a 
short  time  against  the  action  of  the  air,  and  all  substances 
floating  in  it,  thus  assisting  in  the  healing  process. 

The  above  astringents  can  be  administered  by  means  of  the 
atomizer,  the  cotton  pledget,  or  in  the  shape  of  powder.  The 
latter  should  be  mixed  with  some  neutral  substance,  such  as 
pulverized  sugar,  starch,  lycopodium,  etc.,  the  ounce  of  water 
being  replaced  by  one  drachm  of  the  diluent  used.  Tannic  acid, 
sulphate  of  zinc,  and  alum  can,  however,  be  used  in  very  much 
stronger  proportions,  the  former  being  sometimes  applied  pure. 

Powders  are  dissolved  slowly  in  the  mucus,  and  their  con- 
tact with  the  membrane  is  more  prolonged  and  effective,  but 
they  should  only  be  used  when  the  discharges  are  copious, 
owing  to.  their  tendency  to  agglomerate  and  form  obnoxious 
masses. 

STIMULANTS. 

When  applied  to  a  mucous  membrane,  stimulants  suddenly 
increase  its  natural  functions.  This  action,  however,  is  but 
temporary,  and  the  membrane  soon  resumes  its  normal  state. 
If  often  repeated,  this  exaltation  of  normal  powers  becomes 
more  prolonged  each  time,  and  a  low  state  of  inflammation  is 
engendered  in  the  membrane,  by  which  all  its  elements  are 
slowly  multiplied.  In  the  diseased  condition,  what  parts  have 
remained  in  a  healthy  state  have  their  area  gradually  ex- 
tended by  the  increased  nutrition  induced  by  the  augmented 


58  THEEAPEUTICS    OF    THE   NASAL    CAVITIES. 

blood  supply,  until  its  condition  is  sufficiently  improved  to 
enable  it  to  resume  its  physiological  functions. 

Stimulants  are  consequently  indicated  in  affections  in  which 
impaired  nutrition  is  inducing  degeneration  or  atrophy,  but 
contra-indicated  when  that  condition  is  accompanied  by 
ulceration,  on  account  of  their  irritating  action.  They  are 
sometimes  useful  in  acute  inflammation,  by  inducing  a  flow  of 
serum  which  relieves  the  distention. 

Pure  stimulants,  as  with  astringents,  are  hardly  to  be  found. 
All  possess  secondary  properties  which  should  be  taken  into 
consideration  when  used. 

Acldiun  Carbolicum,  gr.  iij-3j. — Disinfectant,  astringent,  and 
anaesthetic.  Its  fumes  relieve  distention  by  stimulating  serous 
glands.  Indicated  in  acute  congestion  and  in  atrophy. 

lodinium  (pure),  gr.  ij  to  glycerine  Ij. — Alterative  and  disin- 
fectant. Its  fumes  produce  same  effects  as  carbolic  acid,  but 
are  more  stimulating. 

Argenti  Nitras,  gr.  x  to  water  5j. — Induces  formation  of  new 
elements,  and  hastens  resolution  of  indolent  ulcerations.  In- 
dicated in  atrophic  conditions. 

Ammonii  Chloridum. — When  nascent  from  the  mingling 
fumes  of  strong  aqua  ammonias  and  muriatic  acid. 

Acidum  Boracicum  (pure  or  3j  to  glycerine  sj).  Slightly 
stimulating ;  promotes  rapid  healing  of  ulcerations. 

Camphor  a  (powdered)  pure  or  as  diluent. — Mild  stimulant 
and  disinfectant.  Indicated  in  acute  inflammation. 

A  drug  deserving  special  mention  and  possessing,  besides  its 
extraordinary  local  anaesthetic  powers,  marked  stimulating 
properties,  is  the 

Hydrochlorate  of  Cocaine,  gr.  ij  to  water  3J. — It  does  not 
possess  any  of  the  irritating  properties  of  the  other  stimu- 
lants, if  pure,  and  exerts  its  influence  solely  upon  the  vascular 
supply  of  the  membrane  by  stimulating  powerfully  and  sud- 


STIMULANTS.  59 

denly  the  vaso-motors.  It  thus  causes  contraction  of  the  ves- 
sels, reducing  the  blood  supply  to  its  minimum,  arrests  pain, 
and  diminishes  the  engorgement  causing  distention.  It  is  not 
only  indicated  in  acute  and  chronic  congestions  of  the  mucous 
membrane,  but  also  where  hypertrophic  changes  have  taken 
place.  It  reduces  the  volume  of  the  growth  to  its  lowest 
limit,  and  facilitates  nasal  respiration. 

Stimulating  steam  inhalations  are  sometimes  accompanied 
with  the  best  results  when  used  in  chronic  affections,  especially 
where  there  is  excess  of  secretion.  Volatile  oils  are  particu- 
larly well  adapted  for  the  purpose,  but  should  be  mixed  with 
light  carbonate  of  magnesia  in  the  proportion  of  half  a  grain 
to  each  drop  of  the  oil,  to  insure  their  being  held  in  suspension 
in  the  water. 

An  inhaler,  such  as  that  in  Fig.  28,  can  be  used,  or  the  hot  water 
placed  in  a  cup  surmounted  by  a  towel  folded  cone-shape,  with 
the  opening  at  the  apex  just  large  enough  to  insert  the  nose. 

Creasotunij  n^x  in  Oss.  water  at  120°. — Disinfectant,  astrin- 
gent, and  resolvent.  Indicated  when  discharges  are  profuse. 

Oleum  Picis,  nixx  in  Oss.  water  at  150°. — Disinfectant  and 
resolvent.  Indicated  when  there  is  ulceration. 

Oleum  Pini  Sylvestris,  n^v  in  Oss.  water  at  140°. — Stimulates 
vessels  principally,  especially  when  these  are  relaxed.  Altera- 
tive and  antiseptic.  Indicated  when  the  discharges  are  pro- 
fuse in  acute  and  uncomplicated  chronic  conditions. 

Oleum  Culebce,  tn,xx  in  Oss.  water  at  150°. — Properties  the 
same  as  those  of  oil  of  pine,  but  less  stimulating. 

Oleum  Eucalypti,  n^xx  to  Oss.  water,  at  130°. — Antiseptic 
and  resolvent.  Indicated  where  membrane  relaxed  and  con- 
gested. 

ALTEKATIVES. 

Local  application  of  alteratives  to  the  mucous  membrane 
also  produce  their  effect  by  influencing  nutrition.  They  in- 


60  THERAPEUTICS    OF    THE   NASAL    CAVITIES. 

(luce  absorption  of  the  morbid  materials  deposited  in  the  sub- 
stance of  the  membrane  through  an  inflammatory  process,  if 
these  are  not  too  firmly  organized.  The  glandular  elements 
are  somewhat  stimulated  and  the  secretions  increased.  They 
are  consequently  indicated  in  those  cases  in  which  hyper- 
trophic  changes  are  taking  place,  or  where  unhealthy  dis- 
charges are  kept  up  through  deficient  action  of  the  glands. 
The  two  principal  alteratives  used  in  nasal  affections,  and  by 
far  the  most  efficient,  are  the  preparations  of  iodine  and  those 
of  mercury. 

Liquor  lodm'ii  Comp.  (Lugol's  Sol.),  niiij-^j. — Somewhat 
stimulating.  Indicated  in  chronic  affections. 

lodoformum,  gr.  x-lx.  Pulv.  Acacia,  33. — Sedative  and  anti- 
septic. Valuable  when  there  is  ulceration. 

Hydrary.  Clilor.  Mil.,  gr.  ^ij-x.  Sacch.  Alb.,  3J. — Soothing. 
Indicated  in  acute  or  subacute  inflammation,  but  contra-indi- 
cated when  ulcerations  are  present. 

Alteratives  are  best  administered  in  combination  with  as- 
tringents. The  latter  hasten  markedly  the  absorption  of  the 
morbid  materials  through  the  mechanical  compression  which 
they  induce. 

SEDATIVES. 

The  facility  with  which  medicines  are  absorbed  by  the 
nasal  mucous  membrane  renders  sedative  applications  very 
effective.  They  soothe  the  membrane  by  limiting  its  func- 
tional activity,  and  by  direct  action  on  the  sensory  nerves. 
They  are  principally  used  to  allay  the  pain  incident  upon 
severe  local  applications.  They  sometimes  arrest  an  acute 
inflammation  when  used  early.  In  the  frontal  headaches 
which  accompany  '  many  nasal  affections,  sedatives  are 
effective,  not  only  by  allaying  the  nervous  irritability  of 
the  parts,  but  by  influencing  the  inflammatory  process. 


SEDATIVES.  61 

t 

After  painful  applications,  or  operations,  the  following  are 
most  effective : 

Erytliroxylon  Coca  (concentrated  infusion). — Applied  with 
atomizer  or  cotton  pledget  immediately  after  operative  pro- 
cedures, arrests  pain  and  limits  subsequent  inflammatory 
symptoms. 

Morphia,  gr.  &-J. — Either  of  its  salts  can  be  used,  in  solution 
or  in  powder,  mixed  with  bismuth  or  lycopodium. 

Belladonna  (extract),  gr.  ij  to  lard  oj. — Soothing  in  acute 
inflammations.  Restricts  nutrition  of  morbid  growths. 

Sedatives  applied  by  steam  inhalations  are  probably  more 
efficient  than  by  any  other  form  of  application.  The  vapor 
of  hot  water  is  in  itself  very  soothing,  and  enhances  greatly 
the  action  of  the  medicines  employed  with  it. 

Benzoin  (compound  tincture),  3J  in  Oss.  water  at  130°. 

Conium  (juice  of),  3J  in  Oss.  water  at  130°. 

Chloroformum,  rr^xx  in  Oss.  water  at  130°. 

Hyoscyamus  (fluid  extract)  3ss  in  Oss.  water  at  130°. 

Acidum  Hydrocyanicum  (dilute),  niiij  in  Oss.  water  at  115°. 

In  some  cases  of  chronic  catarrh,  applications  of  astringents 
and  stimulants,  although  seemingly  indicated,  give  rise  to 
violent  irritation,  thus  doing  more  harm  than  good  by  in- 
creasing the  morbid  process.  Sedative  applications  in  these 
cases  are  generally  followed  by  the  best  results,  especially 
when  used  with  either  of  the  agents  described  in  the  next 
paragraph,  which,  combining  with  the  solution,  forms  a  thin 
coating  over  the  hypersensitive  membrane,  and  protects  it 
against  the  air. 

PROTECTIVES. 

This  class  of  agents  have  for  their  object  the  prevention  of 
the  irritation  occasioned  'by  the  passage  of  air  through  in- 
flamed or  ulcerated  cavities.  They  form,  with  the  secretions 
present,  a  coating  which  covers  the  mucous  membrane  effect- 


62  THEHAPEUTICS    OF    THE    NASAL    CAVITIES. 

ively  and  for  a  certain  length  of  time,  and  protects  it  not  only 
against  the  mechanical  action  of  the  atmospheric  current,  but 
also  against  any  extraneous  substances  it  might  contain. 

Bismuthi  Subnitras,  lycopodium, pulverized  talc,  and  starch  are 
the  most  effective  protectives.  They  are  generally  used  in 
combination  with  the  other  agents  indicated  in  the  case,  acting 
as  diluents. 

ESCHAKOTICS. 

Escharotics  are  frequently  employed  in  the  nasal  cavities 
to  destroy  exuberant  growths,  or  to  limit  by  the  cicatricial 
contraction  which  follows  their  use,  what  power  of  dilatation 
such  growths  may  possess.  They  combine  with  the  tissues 
and  destroy  them;  inflammation  around  the  destroyed  area 
follows,  and  the  latter  is  separated  as  a  slough,  while  all  the 
layers  of  the  membrane  are  consolidated  by  the  hyperplastic 
products  of  the  inflammatory  process.  Mild  escharotics  are 
sometimes  used  to  annul  hypera3sthesia  of  the  superficial 
nerves.  They  destroy  less  tissue,  and  their  action  is  limited 
to  the  surface,  unless  applied  repeatedly.  The  over-sensitive 
nervous  filaments  of  the  cauterized  portion  are  either  de- 
stroyed by  the  disorganizing  action  of  the  agent,  or  covered 
by  the  subsequent  cicatricial  formations. 

Nitric  Acid,  applied  with  small  absorbent-cotton  pledget. 
Diffusive  power  very  great.  Violent  inflammation  follows  too 
extensive  applications.  Used  in  large  hypertrophies. 

Chromic  Acid,  applied  with  metallic  probe,  previously  heated 
and  dipped  in  the  acid.  Penetrates  less  deeply  and  gives  rise 
to  less  pain.  Indicated  in  same  condition,  but  requires  a 
greater  number  of  applications. 

Glacial  Acetic  Acid,  applied  with  absorbent-cotton  pledget. 
Has  great  affinity  for  epithelial  cells.  Power  of  penetration 
limited.  Indicated  in  hypertrophies  of  recent  formation  and 
in  hyperaesthetic  conditions  of  the  membrane. 


PROTECTIVES.  03 

The  addition  of  hydroehlorate  of  cocaine  to  nitric  acid, 
in  sufficient  quantity  to  form  a  saturated  solution,  not  only 
renders  its  application  absolutely  painless,  but  seems  to 
bring  the  inflammatory  process  to  an  early  ending  without 
interfering  with  the  therapeutic  action. 


The  agents  above  described  represent  those  I  have  found  the 
most  effective  in  the  medicinal  treatment  of  affections  of  the 
nasal  passages.  The  list  could  be  much  lengthened  were  I  to 
include  all  those  tried  and  found  of  inferior  value.  An  out- 
line of  the  differential  properties  of  each  drug  having  the 
power  of  inducing  organic  change  "is  added,  because  I  consider 
their  proper  recognition  of  the  greatest  importance,  and  that 
upon  their  intelligent  adaptation  to  each  case  depends  the  suc- 
cess of  the  treatment.  The  thoroughness  with  which  applica- 
tions are  made  to  the  parts  is  not  less  important.  Each  af- 
fected spot  should  not  only  be  carefully  treated  after  thorough 
cleansing,  but  the  applications  should  be  repeated  often  enough 
to  keep  up  a  continuous  effect.  I  doubt  whether  any  applica- 
tion other  than  one  inducing  destructive  metamorphosis  pro- 
duces an  effect  lasting  more  than  four  hours.  It  should  con- 
sequently be  renewed  at  the  end  of  that  time,  and  repeated  as 
nearly  as  possible  at  regular  intervals.  As  the  patient  must 
necessarily  be  intrusted  with  a  part  of  the  treatment,  he  should 
be  carefully  taught  the  manipulation  of  the  atomizer,  douche, 
or  insufflator  prescribed,  and  be  seen  as  often  as  circumstances 
will  permit.  The  different  agents  are  sometimes  exhibited  in 
gelatine  bougies,  medicated  cotton,  etc.  These,  as  well  as  the 
compound  remedies,  such  as  iodo-tannin,  iodide  of  zinc,  etc., 
the  special  remedies,  and  the  formulae  found  most  effective, 
will  be  described  under  the  headings  of  the  diseases  in  which 
they  are  used.  This  will  also  be  the  case  with  internal  medi- 
cation, which,  although  not  always  indicated  in  the  treatment 
of  nasal  affections,  is  sometimes  of  the  greatest  importance. 


CHAPTER  VI. 

DISEASES   OF  THE  ANTEEIOR  NASAL   CAVITIES. 
ACUTE  RHINITIS. 

(Synonj'ms: — Acute  Coryza;  Acute  Nasal  Catarrh;  Acute  Rhinorrhoea; 
Acute  Nasal  Blennorrhoea  ;  Cold  in  the  Head  ;  Snuffles.) 

Etiology. — Acute  inflammation  of  the  nasal  mucous  mem- 
brane is  caused,  in  the  majority  of  cases,  by  exposure  to 
cold  when  the  body  is  overheated.  The  inspiration  of  hot, 
dry  air  is  another  frequent  cause,  while,  less  frequently, 
irritating  vapors,  dust,  and  the  emanations  of  certain  drugs, 
act  as  exciting  agents.  Predisposition  is  an  important 
factor  in  many  cases,  some  persons  being  affected  by  the 
least  exposure  to  any  of  the  exciting  mediums.  Children 
are  particularly  subject  to  it,  while  the  aged  enjoy  compara- 
tive immunity.  A  scrofulous  taint  seems  to  render  the 
mucous  membrane  susceptible  to  frequent  attacks,  and  in 
persons  of  a  rheumatic  diathesis,  it  is  very  often  present.  In 
women  of  a  nervous  temperament,  it  is  occasionally  an 
accompaniment  of  menstruation.  The  affection  forms  a 
prominent  symptom  of  a  number  of  diseases,  such  as  measles, 
scarlatina,  hay  fever,  etc.  It  occasionally  appears  as  an  epi- 
demic, through  atmospheric  perturbations.  As  to  its  con- 
tagiousness, repeated  experiments  have  given  uniformly 
negative  results.  On  the  other  hand,  the  nasal  mucous 
membrane  of  some  individuals  is  exceedingly  sensitive  to 
the  action  of  external  infectious  discharges,  and  acute 
rhinitis  can  be  occasioned  in  them  by  using  the  handkerchief 
of  a  strumous  subject,  repeatedly  kissing  a  person  affected 
with  scrofulous  rhinitis,  etc.  The  coryza  of  nurslings  is 
(64) 


ACUTE   RHINITIS.  65 

often  the  result  of  local  infection  by  the  vaginal  secretions 
of  the  mother  during  birth. 

Pathology. — When  the  attack  is  brought  on  by  exposure 
to  cold,  the  temperature  of  the  surface  exposed  is  suddenly 
brought  below  the  normal  standard.  In  those  persons  in 
whom  the  nasal  membrane  is  the  area  of  least  resistance, 
the  impression  made  on  the  peripheral  nerves  is  transmitted 
through  the  sympathetic  to  the  vaso-motors  of  the  nasal 
membrane,  and  the  result  is  a  sudden  contraction  of  its 
vessels,  soon  followed  by  dilatation.  The  flow  of  the  blood 
through  them  is  first  hastened,  then  slackened,  and  the 
latter  soon  begins  to  accumulate,  continuing  to  do  so  more 
and  more  as  the  current  becomes  slower.  After  some  time 
the  engorgement  becomes  so  great  that  the  serum  transudes 
through  the  vessel-walls,  accompanied  by  leucocytes,  fills 
the  neighboring  parts,  causing  distention,  and  penetrates 
through  the  epithelial  layer  to  the  surface  of  the  membrane, 
dragging  along  with  it  some  of  the  leucocytes  or  pus  cor- 
puscles, and  sometimes  red  corpuscles  and  epithelium.  The 
distention  would  be  limited,  however,  were  the  layer  of 
venous  sinuses,  or  erectile  caverns  termed  the  "  turbinate 
corpora  cavernosa/'  and  situated  between  the  membrane 
proper  and  the  periosteum,  not  present.  These  sinuses, 
most  abundant  over  the  turbinated  bones,  especially  at  their 
posterior  portion,  take  an  active  part  in  the  inflammatory 
process  by  becoming  filled  with  venous  blood.  As  the 
disease  progresses,  the  secretion,  at  first  thin  and  watery 
through  the  action  of  the  over-stimulated  serous  glands, 
which  pour  out  their  normal  secretion  in  excessive  quan- 
tities, becomes  more  and  more  c'harged  with  broken-down 
epithelial  cells,  lymph  corpuscles,  pus  globules,  etc.,  until 
it  assumes  the  character  of  thick,  tenacious  mucus,  or  inuco- 
pus,  according  to  the  cell  elements  held  in  suspension. 

5 


G6  DISEASES   OF   THE   ANTERIOR   NASAL    CAVITIES. 

When  the  affection  is  caused  by  direct  irritation  to  the 
membrane  through  the  agency  of  smoke,  dust,  irritating 
gases,  etc.,  the  glandular  elements  are  probably  the  first 
affected,  and,  becoming  engorged,  act  as  foci  of  the  patho- 
logical process.  An  overheated  atmosphere  induces  the 
latter  by  causing  a  too  rapid  evaporation  of  lubricating 
fluids. 

Symptoms. — The  onset  of  an  attack  of  acute  rhinitis  may 
vary  in  severity  from  a  mere  fit  of  sneezing,  followed  by 
hardly  perceptible  concomitant  symptoms,  to  a  severe  sys- 
temic disturbance,  manifested  by  fever,  notable  rise  of  tem- 
perature, rigors,  etc.  In  the  majority  of  cases,  however, 
the  attack  begins  with  a  sensation  of  dryness  and  fullness 
in  one  or  both  nostrils,  corresponding  with  the  stage  of 
hyper-vascularity.  A  dull  frontal  headache  soon  begins, 
due  to  inflammation  by  continuity  of  tissue  of  the  lining 
membrane  of  the  frontal  sinus,  accompanied  by  creeping, 
chilly  sensations  in  the  back,  and  occasionally  dull,  ephemeral 
pains  in  the  muscles  and  joints.  Intense  itching  in  the 
nasal  cavities  causes  frequent  sneezing,  and  prompts  the 
continual  and  ineffectual  use  of  the  handkerchief. 

"With  the  stage  of  dilatation,  begins  a  free,  watery  dis- 
charge, strongly  alkaline  in  reaction,  and  irritating  to  the 
surfaces  with  which  it  comes  in  contact,  viz.,  the  ala3  of  the 
nose  and  the  upper  lip.  The  decreased  lumen  of  the  cavities 
causes  the  voice  to  acquire  the  peculiar  quality  known  as 
"  nasal  twang,"  which  becomes  more  marked  as  the  occlusion 
increases.  The  eyes  are  usually  suffused  with  tears,  through 
partial  or  entire  closure  of  the  tear  ducts.  Hearing  may 
be  temporarily  impaired,  through  involvement  of  the  Eusta- 
chian  tubes.  The  skin  is  hot  and  the  pulse  rapid,  although 
the  temperature  may  not  be  influenced.  As  the  affection  pro- 
gresses, the  discharge  becomes  thicker  and  thicker  until  it 


ACUTE  KHINITIS.  G7 

assumes  a  muco-purulent  character,  at  times  positively  fetid 
and  nauseating.  About  this  time,  the  affection  either  gradu- 
ally disappears,  or  extends  to  the  pharynx  and  larynx,  in- 
ducing slight  catarrhal  symptoms,  which  generally  last  but 
a  few  days. 

Anterior  rhinoscopy  reveals  a  highly  congested  membrane, 
swollen  •  at  times  to  a  degree  sufficient  to  completely  occlude 
the  cavity.  Pressure  with  a  probe  causes  a  depression  which 
disappears  as  soon  as  the  instrument  is  taken  off.  The 
olfactory  tract  is  generally  but  slightly  affected,  although 
the  sense  of  smell  may  be  completely  obtunded  by  the  tume- 
faction in  the  respiratory  tract,  which  prevents  the  access  of 
odoriferous  particles  to  the  roof  of  the  nose.  The  posterior 
nares  are  also  redder  than  usual,  especially  at  the  posterior 
ends  of  the  turbinated  bones. 

Prognosis. — The  duration  of  an  attack  of  acute  rhinitis, 
varies  from  one  day  to  several  weeks.  It  sometimes  ceases 
with  the  end  of  the  first  stage,  while  at  others,  complications 
cause  it  to  be  prolonged  for  weeks.  Its  termination,  as  far  as 
life  is  concerned,  is,  with  very  rare  exceptions,  always  favora- 
ble. A  few  cases  of  death  have  been  reported  in  nurslings 
and  very  old  people,  caused  by  interference  with  nasal  respir- 
ation in  the  former,  and  bronchial  complications  in  the  latter. 
As  to  sequela?,  the  estimate  usually  given  that  90  per  cent,  of 
the  population  of  the  United  States  are  more  or  less  affected 
with  some  form  of  chronic  rhinitis,  would  indicate  that  acute 
rhinitis,  when  not  an  exacerbation  of  the  chronic  condition, 
is,  in  the  great  majority  of  cases,  the  primary  expression  of 
a  future  state  of  chronicity. 

Treatment. — Success  in  the  treatment  of  acute  rhinitis  de- 
pends entirely  upon  the  length  of  time  between  the  onset  of 
the  affection  and  the  beginning  of  the  treatment.  The  longer 
that  time,  the  smaller  the  chances  of  success,  until  the  disease 


68  DISEASES   OF   THE  ANTERIOR  NASAL   CAVITIES. 

has  become  firmly  established,  when  palliatives  can  alone  be 
given,  and  the  culmination  perhaps  hastened.  If  seen  early, 
an  attack  of  acute  rhinitis  can  generally  be  cut  short.  If 
severe,  the  patient  should  be  placed  in  a  warm  room  and  a 
derivative  treatment  instituted.  I  have  found  that  medicines 
inducing  abundant  diaphoresis  are  most  effective  for  the  pur- 
pose, combined  with  small,  stimulating  doses  of  tincture  of 
opium.  '  The  following  treatment  has  produced  the  most 
satisfactory  results: — The  patient  is  given  a  hot  mustard 
foot-bath  and  put  to  bed,  and  the  following  mixture  is 
administered : 

!  Increases  the  action  of  the  heart  and  the  rapidity  of 
the  circulation,  and  tends  to  maintain  the  fluidity  of 
the  blood  in  the  stage  of  dilatation. 

Relieves  the  irritability  of  the  nervous  filaments 
and  favors  the  action  of  the  above.  Maintains  the 

TillCt.   Opii.  ffl  XXIV.       <       continuity    of    the  blood-current,  thus   preventing   its 

transudation  through  the  vessel-walls,  and  hindering 
the  migration  of  white  corpuscles. 

Saccli.  Alb.  5j- 

Aq.  Camphorae  ad'j- 

M.  Sig.  One  teaspoonful  in  a  half- glassful  of  water  every  hour  three 
times,  then  every  two  hours. 

The  nose  should  be  greased  externally  with  lard  or  cold 
cream  to  limit  the  evaporation  over  its  surface,  while  pulv. 
talc.,  snuffed  or  insufflated  into  the  nostrils,  protects  them 
against  the  irritation  caused  by  the  respiratory  current. 
When  the  headache  is  severe,  fifteen  grains  of  bromide  of 
potassium  added  to  each  dose,  are  very  effective,  by 
inducing  contraction  of  the  arterioles  of  the  membrane 
lining  the  accessory  cavities  and  lessening  its  distention. 
When  the  fever  is  great,  the  chloride  of  ammonium  might 
be  replaced  by  tincture  of  aconite  root,  one  minim  to  the 
dose,  but  not  combined  with  it,  on  account  of  the  antago- 


ACUTE  KHINITIS.  G9 

nistic  action  of  the  two  drugs  on  the  circulation.  The  local 
effect  is  produced  by  the  opium,  assisted  by  the  diaphoretic 
and  diuretic  properties  of  the  aconite,  which  at  the  same 
time  reduces  the  fever.  The  patient  should  not  leave  the 
house  until  at  least  six  hours  after  taking  the  last  dose  of 
medicine,  the  action  of  the  drugs  having  then  ceased.  He 
should  be  warmly  clad. 

The  derivative  action  of  a  purgative  sometimes  aborts  a 
severe  attack  of  rhinitis,  the  salines  being  the  most  effective 
by  causing  liquid  stools.  A  large  dose  of  quinine,  gr.  x-xv, 
repeated  in  six  hours,  has  also  given  good  results.  If  the 
patient  is  first  seen  when  the  affection  has  run  into  the  stage 
of  dilatation  with  free  discharge,  the  hydrochlorate  of  pilocar- 
pine  in  doses  of  gr.  &,  in  water,  repeated  every  two  hours  until 
free  diaphoresis  has  been  obtained,  is  sometimes  very  effec- 
tive. It  first  increases  the  fullness  in  the  nostrils  and  the  flow 
of  secretion,  these  being  soon  relieved  by  profuse  perspi- 
ration. When  the  latter  has  decreased  somewhat  the  patient 
is  briskly  rubbed  with  a  rough  towel,  under  the  blankets, 
until  the  skin  becomes  quite  red.  He  is  then  allowed  to  sleep 
and  will  generally  awaken  much  relieved,  and  at  times  cured. 

Ordinary  cases  of  acute  rhinitis  can  generally  be  aborted  if 
seen  in  the  first  stage,  and  often  in  the  second,  by  the  fol- 
lowing powder : 

Counteracts  the  local   paretic  influence  upon  vaso- 

R.    Morph.HydrOChlor.,gr.ij.       \      motors    and  stimulates  .helocal  and  gene^l  drcuh- 
J  J  tion;    relieves  the   frontal   headache  by  reducing   the 

nervous  irritability. 

A  Inminia  Antagonizes  the  vascular  dilatation  of  the  first  stage 

Y  ,•  (      and  prevents  or  arrests  serous  transudation. 

Bismuth!  Garb.  f 

n    i        m    i  _    ~.        S          Protect! ves. 

Pulv.  Talc  aa  9j.     ( 

M.  et  ft.  chart.  No.  xx. 

S.     Insufflate  one  powder  in  each  nostril  every  two  hours,  after  clear- 
ing  the  nose. 


70  DISEASES   OF  THE  ANTERIOR  NASAL   CAVITIES. 

Stimulating  inhalations  are  sometimes  very  effective,  by 
inducing  a  copious  flow  of  serum,  which  relieves  the  tension 
of  the  membrane,  causing  contraction  of  the  blood-vessels. 
The  fumes  generated  by  mixing  pure  iodine  and  carbolic  acid 
are  especially  beneficial.  A  couple  of  drops  are  placed  on  a 
small  piece  of  absorbent  cotton,  previously  introduced  into 
the  bulb  of  the  insufflator  shown  in  Fig.  25,  and  the  opening 
is  closed  with  a  stopper.  The  patient  uses  the  instrument 
himself,  his  breath  mixing  with  and  warming  the  fumes, 
which  are  thus  better  prepared  to  meet  the  irritated  mem- 
brane. This  method  is  especially  useful  when  the  Eustachian 
tubes  and  accessory  cavities  are  involved  in  the  inflammatory 
process.  By  closing  the  other  nostril  with  the  finger,  the 
nasal  cavities  are  tightly  closed  when  the  act  of  blowing  is 
performed  through  the  mouth,  and  the  velum  palati  adapts 
itself  closely  against  the  pharynx.  Finding  no  other  issue, 
the  medicated  atmosphere  must  of  necessity  penetrate  into 
the  accessory  cavities  and  Eustachian  tubes,  especially  the 
latter.  The  essential  oils  of  tar,  eucalyptus,  and  cubebs  can 
be  used  with  advantage  in  the  same  manner. 

I  have  of  late  been  using,  with  much  success,  a  four  per 
cent,  solution  of  the  hydrochlorate  of  cocaine.  This  agent, 
by  stimulating  powerfully  the  vaso-motors  of  the  membrane, 
antagonizes  the  vaso-motor  paresis,  thus  counteracting  the 
vascular  engorgement  and  the  transudation.  It  is  serviceable 
in  all  the  stages  of  the  affection.  It  is  best  applied  with  the 
cotton-carrier,  a  thin  film  of  absorbent  cotton  being  employed. 
The  membrane,  previously  dried  as  effectively  as  possible 
with  another  cotton-carrier,  is  freely  covered  with  the  solu- 
tion. At  the  end  of  a  couple  of  minutes,  the  distended 
membrane  having  suddenly  depleted  itself  and  collapsed, 
the  "  stuffiness "  completely  disappears,  and  does  not  return 
until  about  three-quarters  of  an  hour  later.  A  renewal  of  the 


SIMPLE   CHKONIC  RHINITIS.  71 

application  is  followed  by  the  same  result,  while,  after  a 
third  application,  the  distention  and  consequent  stenosis  do 
not  generally  recur.  Five  or  six  consecutive  applications 
are  sometimes  necessary. 

Galvano-caustic  applications,  by  suddenly  stimulating  the 
vaso-motors,  are  also  very  effective,  the  flat  side  of  the  knife 
at  cherry  heat,  being  applied  two  or  three  times  to  the  most 
prominent  portions  of  the  distended  membrane. 

SIMPLE   CHRONIC   RHINITIS. 

(Synonyms: — Chronic  Coryza;   Chronic  Blennorrhoea ;  Chronic  Rhinor- 
rhoea;  Chronic  Nasal  Catarrh :  Purulent  Catarrh ;  Fluxus  Nasalis.) 

Etiology. — Chronic  inflammation  of  the  nasal  mucous  mem- 
brane is  generally  the  result  of  repeated  acute  attacks.  At 
times,  however,  it  seems  to  occur  without  any  apparent 
primary  condition,  assuming  from  the  first  the  symptoms 
of  chronicity.  It  is  a  frequent  sequel  to  the  rhinitis  of  the 
newborn,  while  in  persons  of  debilitated  constitution  and 
in  the  aged,  it  often  presents  itself  in  the  form  of  a  watery 
flux,  non-irritating  in  character,  but  sometimes  very  profuse. 
Certain  occupations  favor  its  development  by  exposing  the 
mucous  membrane  to  the  irritating  action  of  an  atmosphere 
loaded  with  dust,  smoke,  etc.  Weavers,  for  instance,  are 
seldom  free  from  it,  while  the  majority  of  carpenters  and 
cigar-makers  are  affected  more  or  less.  It  is  frequently  seen 
in  smokers,  not  as  a  result  of  the  habit  proper,  but  on  account 
of  the  irritating  character  the  surrounding  atmosphere  ac- 
quires when  contaminated  with  smoke.  Certain  substances,, 
among  which  may  be  mentioned  arsenic,  bichromate  of 
potash,  the  fumes  generated  by  the  action  of  muriatic  acid 
on  lead  solder,  and  the  emanations  of  caustic  acids,  when 
inhaled  for  a  certain  length  of  time,  as  is  the  case  with 


72  DISEASES   OF  THE  ANTERIOR  NASAL   CAVITIES. 

workmen  manufacturing  or  using  them,  frequently  produce 
chronic  rhinitis,  followed  at  times  by  perforation  of  the 
nasal  septum. 

Patholoffy. — Frequent  inflammatory  manifestations  in  the 
nasal  mucous  membrane,  whether  due  to  the  action  of  cold 
or  to  that  of  a  local  irritant,  gradually  reduce  to  permanency 
the  abnormal  condition  of  the  vascular  supply  accompanying 
an  acute  attack.  The  repeated  distentions  to  which  the 
vessels  have  been  subjected,  cause  them  to  lose  their  con- 
tractile power,  and  they  remain  distended.  Their  walls  be- 
come softened  and  more  permeable,  and  blood-elements 
escape  continually  by  a  process  of  nitration.  These  blood- 
elements,  however,  now  contain  more  white  corpuscles, 
many  of  which  crowd  into  the  connective  tissue  under  the 
epithelial  layer,  thus  inducing  induration  and  thickening, 
while  others,  having  become  metamorphosed  into  pus  cells 
and  unripe  epithelial  cells,  penetrate  through  the  epithelium, 
and  with  the  glandular  secretion,  form  the  muco-purulent 
discharge  frequently  accompanying  the  affection.  The  tur- 
binate  corpora  cavernosa  take  part  in  the  inflammatory 
process  but  slightly,  although  their  power  of  erection  is 
more  susceptible  to  manifest  itself  upon  the  least  exposure. 

Symptoms. — When  the  affection  is  the  result  of  frequent 
colds,  the  membrane  becomes  turgescent  upon  the  least 
exposure,  and  all  the  local  symptoms  of  the  acute  condition 
appear.  Each  exacerbation  distending  the  membrane  more 
and  more,  resolution  becomes  slower  with  each  attack,  until 
a  state  of  permanent  "cold  in  the  head'?  is  engendered, 
accompanied  by  more  or  less  discharge  of  thick,  tenacious, 
translucent  mucus,  which  sometimes  assumes  a  purulent 
character,  and  is  generally  drawn  through  the  posterior 
nares  into  the  mouth,  and  expectorated  or  swallowed. 
Sneezing  is  a  frequent  symptom,  most  evident  during  the 


SIMPLE   CHRONIC   RHINITIS.  73 

exacerbations,  and  in  a  large  proportion  of  cases,  the  tip 
and  alre  of  the  nose  are  pinkish  and  sometimes  quite  red. 
These  symptoms  are  in  abeyance  during  warm  weather,  to 
resume  all  their  vigor  with  the  first  damp  days  of  Fall. 

In  the  variety  sometimes  termed  "traumatic  rhinitis,"  in 
which  the  trouble  is  due  to  constant  local  irritation,  the 
most  marked  symptom  is  increased  secretion,  in  the  form 
of  a  thick,  creamy  substance,  also  generally  voided  through 
the  posterior  nares.  When  the  condition  has  lasted  for  some 
time,  the  discharges  become  purulent,  and  occasionally  form 
small  greenish  masses,  which  can  be  seen  adhering  here  and 
there,  connecting  like  bridges  the  two  sides  of  the  cavity, 
and  occasionally  imparting  to  the  breath  a  peculiar  heavy 
odor.  A  hot,  dry,  spicy  sensation  is  frequently  complained 
of,  located  not  only  in  the  nose,  but  also  in  the  pharyngeal 
vault  and  pharynx,  these  appearing,  upon  examination,  con- 
gested and  parched.  Itching  caused  by  the  accumulation 
of  irritating  particles  in  the  anterior  portions  of  the  nostrils, 
prompts  the  frequent  introduction  of  the  fingers,  and  the 
septum  sometimes  becomes  perforated  through  repeated 
scratching,  and  as  a  result  of  the  long-continued  contact 
with  the  bulk  of  the  irritating  fumes  or  particles  as  they 
enter  the  cavity.  Pain  over  the  brow  is  often  present, 
coupled  with  a  feeling  of  weight,  due  to  inflammatory 
narrowing  of  the  infundibulum,  the  canal  connecting  the 
frontal  sinus  with  the  nasal  cavities.  The  Eustachian  tubes 
are  occasionally  involved,  through  extension  of  the  inflam- 
mation into  them.  The  symptoms  continue,  regardless  of 
seasons  (provided,  of  course,  that  the  causes  of  irritation  are 
continued),  differing  in  this  from  the  chronic  rhinitis  due  to 
repeated  colds. 

In  a  small  proportion  of  cases,  and  especially  in  persons 
of  advanced  age,  the  complaint  consists  of  a  profuse  watery 


74  DISEASES   OF   THE   ANTEKIOK   NASAL    CAVITIES. 

secretion,  so  abundant  at  times  as  to  cause  great  annoyance. 
A  sensation  of  itching  is  felt  as  the  fluid  trickles  along  the 
intra-nasal  walls,  which  adds  much  to  the  patient's  distress. 
The  other  symptoms  of  chronic  rhinitis  are  usually  absent. 

The  appearances  of  the  parts,  anteriorly  and  posteriorly, 
differ  with  the  causes  of  the  affection.  In  the  variety  re- 
sulting from  repeated  colds,  the  membrane  covering  the 
middle  and  inferior  turbinated  bones  and  the  septum,  may 
not  appear  redder  than  in  the  normal  state.  This  is  espec- 
ially the  case  with  children,  notwithstanding  the  great 
amount  of  discharge  which  accompanies  the  affection  in 
them.  In  adults  the  membrane  is  usually  congested,  some- 
times almost  livid,  and  if  seen  during  an  exacerbation,  bulges 
out,  often  sufficiently  to  touch  the  septum.  The  bulging 
portion  pits  under  pressure  and  resumes  its  previous  state 
sluggishly  when  the  pressure  is  removed.  In  the  traumatic 
variety,  the  membrane  is  always  found  highly  congested, 
and  bleeds  when  touched  with  a  probe.  It  is  not  so  prone 
to  turgescence,  the  inflammatory  process  being  confined 
principally  to  the  superficial  layers  and  involving  but 
slightly  the  corpora  cavernosa.  When  the  condition  is 
due  to  exposure  to  cold,  on  the  contrary,  the  external  in- 
fluence is  transmitted  through  the  sympathetic  to  the  vaso- 
niotors  of  all  the  layers,  and  the  corpora  cavernosa  take 
part  in  the  inflammatory  process  as  much  as  the  other 
layers.  In  the  chronic  rhinitis  characterized  by  a  watery 
flux,  the  membrane  is  usually  pale,  sometimes  blanched. 
The  pharyngeal  vault  takes  part  more  or  less  in  the  three 
varieties  of  the  affection,  and  its  color  corresponds  with  that 
of  the  anterior  nasal  cavities. 

Prognosis. — If  left  to  itself,  chronic  rhinitis  either  remains 
stationary,  or  gives  rise  to  hypertrophic  changes  in  the 
layers  of  the  membrane.  It  is  generally  the  starting  point 


SIMPLE   CHRONIC   RHINITIS.  7o 

of  polypi,  and  is  frequently  the  origin  of  catarrhal  occlu- 
sion of  the  Eustachian  tubes.  When  properly  treated,  the 
chances  of  recovery  are  very  favorable,  provided  the  irri- 
tating cause  be  removed.  Eecurrence,  however,  is  very 
frequent  when  the  affection  occurs  as  the  result  of  repeated 
attacks  of  acute  rhinitis  brought  on  by  cold.  This  is  es- 
pecially the  case  with  the  aged,  and  in  debilitated  constitu- 
tions. 

Treatment. — The  success  of  the  treatment  depends  greatly 
upon  a  proper  recognition  of  the  cause  of  the  trouble  in 
each  individual  case.  Cleanliness  is  of  prime  importance, 
especially  when  the  affection  is  due  to  local  irritation  by 
extraneous  matters,  but  great  circumspection  should  be 
used  in  selecting  the  proper  instrument.  A  too  powerful 
stream  would  act  as  a  local  irritant,  and  while  performing 
its  office  as  a  cleansing  agent,  would  increase  the  inflam- 
matory process  and  encourage  hypertrophic  changes.  The 
atomizer  is  undoubtedly  the  best  instrument  for  the  pur- 
pose, providing  its  spray  be  coarse  enough  to  bathe  the 
membrane  thoroughly,  and  wash  away  accumulated  dis- 
charges. As  to  the  solution  to  be  employed,  preference 
should  be  given  to  one  combining  with  its  cleansing  prop- 
erties, that  of  reducing  local  congestion.  The  following 
combination  has  proven  itself  very  effective  in  the  fulfill- 
ment of  these  conditions : — 

at.    oOClll  .DICarD.  I          Alkalinize  the  solution  and  give  it  proper  specific 

Sodii  Bibor.  aa  gr.  Vlij.       (      gravity.     Antiseptic  and  solvent. 

Ext.  fld.  PlnUS  Canad.  (          Astringent  and  antiseptic.     Contracts  the  capillaries 

•/       and  the  glands,  diminishing  secretion  and  encouraging 
"l.2tv.       ^      the  absorption  of  inflammatory  products. 

Glycerin®  5u- 

Aquam  ad  5iv. 

In  the  variety  originating  from  repeated  colds,  the  above 
should  be  applied  with  the  atomizer  sufficiently  often  to 
keep  the  membrane  free  of  accumulated  discharges.  This 


76 


DISEASES   OF   THE   ANTERIOR  NASAL   CAVITIES. 


requires  generally  two  or  three  applications  daily,  each  of 
three  or  four  minutes'  duration.  A  few  days  of  thorough 
cleansing  generally  limit  the  active  congestion  markedly, 
and  the  membrane  is  prepared  to  undergo  active  treat- 
ment. In  mild  cases,  the  mere  continuation  of  the  spray 
is  sometimes  sufficient,  through  the  astringency  of  the  ex- 
tract of  pine,  to  cause  the  membrane  to  regain  its  normal 
state,  but  such  is  not  the  case  when  the  condition  has  pro- 
gressed for  a  certain  length  of  time;  more  active  measures 
must  be  adopted  to  counteract  the  inflammatory  process; 
the  new  products  must  be  absorbed  and  the  tone  of  the 
vessels  returned  to  its  normal  standard.  Of  many  prepa- 
rations and  combinations  tried  for  the  purpose,  the  glycerite 
of  carbolized  iodo-tannin,  prepared  as  follows,  has  produced 
for  me  the  most  satisfactory  results  :  — 


R      Torlinii 

Acidi  Tannici 


Stimulates  the  absorbents,  inducing  absorption  of  in- 
flaramatory  products. 

Causes  contraction  of  blood-vessels,  superficial  and 

,deep:  gi!ins  them  ton<?nd  hardening  the;r  ™lls'  thus 

limiting  infiltration  and  nutrition.     Stimulates  absorp- 
tion  of  new  elements  by  mechanical  constriction. 


Aquse  Oss. 

Mix,  filter,  and  evaporate  to  |ij,  and  add 

Glycerinae  %iv. 

5  In  weak  solution  reduces  superficial  hyperaesthesia, 
rendering  membrane  less  sensitive  to  atmospheric  per- 
turbations and  irritating  particles.  Antiseptic  and 
slightly  astringent. 

This  preparation  forms  a  clear  solution,  which  remains 
in  contact  with  the  membrane  for  a  considerable  period 
on  account  of  its  oily  consistence.  In  order  to  obtain  the 
best  effects,  it  should  be  applied  several  times  daily,  each 
time  after  thorough  cleansing.  The  patient  must  conse- 
quently be  taught  to  conduct  the  applications  himself,  and 
to  use  a  feather,  the  most  efficient  and  the  safest  instrument 
for  the  purpose.  This  being  dipped  in  the  solution,  is  in- 
troduced into  the  nasal  cavity  and  so  manipulated  as  to 


SIMPLE  CHRONIC  RHINITIS.  77 

bathe  the  mucous  lining  thoroughly.  In  most  cases  the 
end  of  the  feather  can  be  pushed  back  into  the  posterior 
nasal  cavity,  and  these  parts  can  thus  take  part  in  the 
treatment.  The  applications  should  be  made  on  rising, 
twice  during  the  day,  and  on  retiring,  thus  maintaining 
a  steady  action,  an  essential  factor  in  the  treatment.  Busi- 
ness men,  who  cannot  return  home  during  the  day,  can 
keep  a  small  vial  of  the  solution  at  their  place  of  business, 
the  feather  being  so  connected  with  the  stopper  as  to  dip  in 
the  preparation  when  the  latter  is  not  in  use.  They  are  thus 
able  to  continue  the  applications  at  regular  intervals  during 
the  day,  after  clearing  the  nose  as  well  as  possible  with  the 
handkerchief.  The  patient  should  be  seen  twice  or  three 
times  a  week,  and  thorough  applications  made  to  the  an- 
terior and  posterior  nares,  using  for  the  former  the  small 
cotton-carrier  (Fig.  20),  and  for  the  latter  a  cotton  pledget, 
held  in  the  grasp  of  the  post-nasal  forceps  (Fig.  22).  At 
times,  the  good  effect  may  be  enhanced  by  alternating  with 
other  remedies,  such  as  the  iodide  of  zinc  (gr.  v-!j),  and 
the  sulpho-carbolate  of  zinc  (gr.  ij-lj),  both  of  which  pro- 
duce their  therapeutic  action  by  inducing  absorption  of  the 
inflammatory  products  and  stimulating  the  blood-vessels.  A 
two  per  cent,  solution  of  hydrochlorate  of  cocaine,  applied 
night  and  morning,  produced  excellent  results  in  the  two 
cases  in  which  it  was  used. 

Powders  are  sometimes  preferable  in  the  treatment  of 
these-  cases,  especially  when  the  discharge  is  very  profuse. 
The  following  will  be  found  effective : — 

R.    Hvdrarff.  Clllor.  Mit.             >  Action  the  same  as  the  iodine  in  the  preceding  for- 

"^  mula. 

f  Substituted  for  the  tannin  on  account  of  its  greater 

Pulv.  AluminiS     aa  5SS«  power  over  serous  glands.     Its  effect  on  blood-vessels 

V  the  same. 

Morphias  Hydrochlor.        ( 

•s          Reduces  hyperxsthesia. 

gr.  n.      C 


F8  DISEASES   OF   THE   ANTEKIOK  NASAL   CAVITIES. 

Bisrnutlii  Subnit.       5j«  Protective. 


5SS>       ~          Disinfectant. 

M.  ct  fiat  ptilv.  j. 

After  cleansing  the  nose  thoroughly,  if  possible,  with  the 
atomizer,  if  not,  with  the  handkerchief,  a  pinch  of  the 
powder  can  either  be  snuffed  or  introduced  into  the  nostrils 
with  the  auto-insufflator  (Fig.  27).  The  latter  method  is  of 
course  much  more  effective,  the  powder  being  more  evenly 
distributed.  Blowing  the  nose  should  be  avoided  for  at 
least  ten  minutes  after  the  application.  Repeated  four  or 
five  times  daily,  this  procedure  soon  limits  the  excessive 
discharge,  and  after  some  time  frequently  restores  the  mem- 
brane to  its  normal  state. 

When  during  an  exacerbation  the  degree  of  stenosis  is 
great,  indicating  extensive  distention  of  the  membrane,  the 
application  of  an  escharotic  over  a  limited  area  is  indicated. 
One  application  of  nitric  acid  generally  suffices  for  each 
nostril.  The  small  cotton-carrier  shown  in  Fig.  20  is  the 
most  desirable  instrument  for  the  purpose,  the  diminutive 
thickness  of  the  blade  enabling  the  operator  to  wrap  a  thin 
film  of  cotton-wool  around  its  tip,  and  still  form  a  very 
small  volume.  The  nostril  being  well  dilated  and  illumi- 
nated, the  end  of  the  cotton-carrier  is  dipped  into  the  acid 
and  pressed  against  a  piece  of  blotting-paper,  so  as  to  part 
with  any  excess  of  acid  and  prevent  dripping.  It  is  then 
introduced  into  the  nose  and  drawn  rapidly  along  the  whole 
length  of  the  most  prominent  portion  of  the  inferior  or 
middle  turbinated  bone,  or  both,  as  the  case  may  be,  taking 
care  not  to  touch  the  septum.  A  sharp  pain  follows  if  the 
acid  is  applied  pure,  which  will  be  avoided  if  hydrochlorate 
of  cocaine  has  previously  been  dissolved  in  it  to  saturation. 
A  long  narrow  eschar  is  the  result,  which  upon  healing  forms 


SIMPLE   CHKONIC   EHINITIS.  79 

a  cicatrix  which  prevents  future  distention,  this  being  as- 
sisted by  the  consolidation  induced  in  the  deeper  layers  of 
the  membrane  by  the  acute  inflammatory  process  following 
the  cauterization.  Galvano-cautery,  which  will  be  described 
under  the  next  heading,  can  be  used  with  advantage  instead  of 
the  acid,  the  edge  of  the  knife,  at  cherry  heat,  being  introduced 
into  the  most  prominent  portions  of  the  membrane. 

In  all  applications  of  this  character,  there  is  danger  of 
inflammatory  adhesion  with  the  septum,  when  the  parts 
are  in  close  apposition.  To  guard  against  this,  the  patient 
should  be  seen  in  a  couple  of  days,  and  if  any  tendency  to 
adhesion  should  show  itself,  i.e.,  bands  of  soft  tissue  con- 
necting the  burnt  area  with  the  opposite  surface,  they  should 
be  torn  by  passing  a  probe  through  them,  and  a  cotton  wad, 
anointed  with  cosmoline,  interposed. 

In  the  treatment  of  this  form  of  nasal  affection,  more  than 
in  any  other,  easily  digested  food,  cleanliness  and  avoidance 
of  exposure  to  sudden  changes  of  temperature  are  fully  as 
important  as  the  local  treatment,  and  should  receive  care- 
ful attention. 

In .  the  majority  of  the  cases  of  so-called  "  nasal  catarrh" 
we  are  called  upon  to  treat,  the  nasal  obstruction  is  due  to 
a  permanent  turgescence  of  the  membrane,  in  which  all  the 
phenomena  accompanying  one  of  the  exacerbations  above 
described  are  present.  This  condition  is  frequently  mistaken 
for  hypertrophic  rhinitis,  and  treated  as  such.  It  can  be 
recognized,  however,  by  noting  the  sluggish  recoil  of  the  tur- 
gescent  membrane  when  pressure  upon  it  with  a  probe  is 
suddenly  discontinued,  and  the  completeness  of  its  collapse 
under  the  influence  of  a  four  per  cent,  solution  of  hydro- 
chlorate  of  cocaine. 

Systematic  pressure  by  means  of  bougies  is  sometimes 
very  effective  in  this  form  of  the  affection.  Those  generally 


80  DISEASES    OF   THE   ANTERIOR   NASAL   CAVITIES. 

used  are  either  metallic,  or  made  of  medicated  gelatine.  The 
former  give  rise  to  much  pain,  and  for  that  reason  are  not 
recomniendable.  As  to  the  latter,  their  soft  consistence  and 
their  small  diameter  enable  them  to  be  introduced  into  the 
nasal  passages  without  difficulty.  Gentle  pressure  is  exerted, 
and  the  medicament  is  kept  in  contact  with  the  membrane 
until  the  bougie  has  become  completely  liquefied.  They  are 
introduced  with  a  rotatory  motion,  and  left  in  position 
until  complete  liquefaction  has  taken  place,  which  generally 
requires  about  twenty  minutes.  The  head  should  be  tilted 
backward  while  the  bougie  is  in  place,  so  as  to  enable  the 
liquefied  gelatine  to  escape  through  the  posterior  nares. 
This  procedure  should  be  repeated  twice  daily.  I  have  ob- 
tained more  satisfactory  results,  however,  by  using  flat 
bougies  instead  of  round  ones,  and  by  having  them  so 
made  that  a  much  longer  contact  with  the  membrane  is 
necessary  to  cause  their  liquefaction.  The  first  modifica- 
tion increases  their  mechanical  efficiency,  by  enabling  them 
to  be  passed  between  the  septum  and  the  edges  of  the  middle 
and  inferior  turbinated  bones,  the  usual  sites  of  greatest 
turgescence,  thus  locating  the  pressure  where  it  is  most  re- 
quired. Eound  bougies  are  held  with  difficulty  in  this  posi- 
tion, and  in  the  majority  of  cases  slip  into  the  meati.  Their 
rapid  liquefaction  causes  them  to  as  rapidly  reduce  their 
diameter,  and  the  pressure  is  reduced  in  proportion.  By 
means  of  the  second  modification,  the  decrease  in  size  is  very 
slow  and  gradual;  the  pressure  is  therefore  more  continuous 
and  even,  and  the  contact  of  the  medicament  with  the  infil- 
trated membrane  more  prolonged. 

The  applications  are  best  begun  with  the  smallest  caliber,  one 
of  these  being  introduced  twice  daily.  The  first  day,  it  should 
remain  in  situ  but  a  couple  of  minutes  each  time,  to  accustom 
the  membrane  to  its  pressure.  Pain  is  seldom  complained 


SIMPLE   CHRONIC  KHINITIS. 


81 


of,  the  discomfort  consisting  principally  of  an  intense  itching 
sensation  and  lachrymation,  which  disappear  after  a  few  sit- 
tings. Two  minutes  being  added  each  day,  at  the  end  of  the 
first  week,  each  application  lasts  about  a  quarter  of  an  hour. 
No.  2  should  then  be  introduced,  beginning  and  gradually 
increasing  as  with  No.  1,  two  minutes  the  first  day,  four  the 
second,  etc.  With  the  third  week,  No.  3  is  brought  into 
requisition  and  used  in  the  same  manner,  while  No.  4  can 
be  employed  the  fourth  week,  if  necessary.  When  the 
cavity  has  become  sufficiently  dilated,  the  use  of  the 


Fig.  29. 


I     2 


Flat  and  crescentic  nasal  bougies. 

last  bougie  employed  should  be  continued  for  some  time, 
gradually  diminishing  the  number  of  applications  until 
one  is  made  during  the  day,  then  every  other  day,  etc. 
When  the  mucous  membrane  is  very  sensitive,  the  first 
few  applications  can  be  preceded  with  advantage  by  a  local 
application  of  a  two  per  cent,  solution  of  hydrochlorate  of 
cocaine. 

In  a  large  proportion  of  the  cases,  the  turgescence  pro- 
jects downward  from  the  free  border  of  either  the  middle 
or  the  inferior  turbinated  bodies,  or  both,  occluding  more  or 

6 


82  DISEASES   OF  THE  ANTERIOR  NASAL   CAVITIES. 

less  the  meati.  When  this  condition  is  present,  I  use  the 
crescentic  bougies  shown  in  Fig.  29,  introducing  them  my- 
self once  every  day,  so  that  the  pendant  portion  rests  in 
the  concavity,  and  direct  the  patient  to  use  the  flat  bougies 
every  morning.  The  latter  he  can  apply  with  the  greatest 
ease,  the  shape  of  the  instrument  forcing  it  to  enter  where 
it  is  needed.  As  to  the  former,  however,  they  are  less  easily 
applied  in  their  proper  position,  and  should  only  be  intro- 
duced by  the  physician. 

The  bougies,  whether  round,  flat,  or  crescentic,  containing 
either  of  the  following  ingredients,  have  been  found  most 
serviceable  in  this  affection:  Hydrastis  Canadensis,  gr.  v; 
Erythroxylon  Coca,  gr.  x;  Ext.  Belladonnas,  gr.  £;  Boro- 
Glyceride,  gr.  v;  Ergotin,  gr.  v.  A  complete  list,  with  indi- 
cations, will  be  found  in  the  Appendix. 

The  drawback  attending  this  method  of  treatment,  how- 
ever, is  that  the  relief  is  but  temporary.  If  no  measure  be 
taken  to  maintain  the  membrane  in  the  position  to  which 
the  bougies  have  returned  it,  in  a  year,  at  most,  the  mem- 
brane will  have  relapsed  into  its  former  condition.  This  can 
be  avoided,  however,  and  the  cure  rendered  complete,  by 
applying  an  escharotic  to  the  membrane,  in  two  or  three 
places,  limiting  each  application  to  an  area  not  larger  than 
a  millet  seed,  and  located  as  far  apart  as  possible  on  the  sur- 
face of  each  turbinated  bone  affected.  This  will  be  followed 
by  cicatricial  bands,  which  will  bind  the  membrane  down, 
as  it  were,  and  cause  it  to  maintain  its  proper  thickness. 
Galvano-cautery  is  the  most  satisfactory  agent  for  the  pur- 
pose, but  when  this  is  not  at  hand,  nitric  acid  can  be  used 
in  the  manner  indicated. 

When  the  affection  is  due  to  local  irritation,  it  stands  to 
reason  that  a  permanent  cure  can  only  be  expected  on  the 
condition  that  the  exposure  to  the  irritating  substances  be 


SIMPLE   CHUONIC  RHINITIS.  83 

discontinued.  In  most  cases,  however,  a  change  of  occu- 
pation is  an  impossibility,  and  the  only  course  to  be  pursued 
is  to  mitigate  the  deleterious  effects  by  keeping  the  nasal 
cavities  as  clean  as  possible,  and  by  protecting  the  mem- 
brane against  the  offending  substances  during  exposure.  The 
method  of  cleansing  and  the  formula  described  above,  are 
especially  valuable  in  this  class  of  cases.  The  patient  should 
be  carefully  taught  the  manipulation  of  the  instrument  and 
directed  to  use  it  after  his  day's  work,  on  retiring  and 
rising.  At  work  he  should  wear,  in  each  nostril,  a  piece 
of  loose  cotton-wool,  which  will  act  as  a  sieve,  and  retain 
the  greater  part  of  the  foreign  matter  floating  in  the  atmos- 
phere. The  same  medicinal  treatment  as  that  described  for 
the  preceding  variety  of  chronic  rhinitis  is  indicated,  the 
pathological  processes  of  both  being  identical.  When  the 
local  inflammation  is  caused  by  the  fumes  of  acids,  etc.,  the 
officinal  belladonna  ointment,  used  several  times  daily,  seems 
to  be  the  most  effective  application,  the  protection  afforded 
by  the  excipient  against  their  irritating  action  doubtless 
coming  in  for  a  large  share  of  the  good  effect.  In  this  way, 
cosmoline  is  also  useful.  The  cotton  wad  should  also  be 
worn  by  these  cases,  and  by  dipping  it  occasionally  in  a 
saturated  solution  of  bicarbonate  of  sodium,  the  acid  fumes 
will  be  partially  neutralized  when  inhaled,  thus  losing  much 
of  their  irritating  property. 

In  the  variety  of  chronic  rhinitis  characterized  by  profuse 
watery  secretion,  cleansing  is  obviously  unnecessary.  The 
watery  flux  being  due  to  complete  relaxation  of  the  mem- 
brane, astringents  are  indicated  to  induce  contraction  of  the 
elements  entering  into  its  composition.  Their  action  is  but 
temporary  however,  unless  coupled  with  a  systemic  treatment 
calculated  to  counteract  the  paretie  state  of  the  local  blood- 
vessels. The  condition  is  at  best  exceedingly  difficult  to 


84  DISEASES   OF   THE   ANTERIOR   NASAL   CAVITIES. 

treat  successfully.  Powdered  alum  gr.  j  in  talc  gr.  ij,  applied 
with  the  auto-insufflator  four  times  daily,  has  served  the 
best  for  the  local  treatment,  with  sulphate  of  strychnia 
gr.  CV>  gradually  increased  to  gr.  ^  internally  administered 
three  times  daily,  after  meals.  A  weak  faradic  current 
passed  through  the  nose  by  placing  one  of  the  poles  on 
each  side  of  its  external  surface  below  the  bridge,  care- 
fully wetting  the  sponges  to  insure  penetration,  is  sometimes 
followed  with  gratifying  results,  especially  if  combined  with 
the  medicinal  treatment  described. 

In  some  cases,  the  local  irritation  is  so  great  that  seda- 
tive applications  can  alone  be  borne.  Much  relief  can  be 
afforded  by  using  as  cleansing  agent,  the  bromide  of  potash 
solution  (gr.  xv-Ij)  with  the  atomizer,  three  or  four  times 
daily.  Slight  .anaesthesia  is  induced,  and  the  membrane  is 
not  influenced  by  the  passage  of  the  air-current  and  what 
foreign  particles  it  might  contain.  An  exceedingly  effective 
application  in  these  cases,  is  a  two  per  cent,  solution  of 
hydrochlorate  of  cocaine,  applied  every  three  hours  with  a 
camel's  hair  pencil.  It  not  only  modifies  the  superficial 
irritability,  but  limits  markedly  the  general  congestion  by 
causing  contraction  of  the  blood-vessels  and  sinuses.  One 
drachm  of  the  solution  will  last  three  or  four  days  if  used 
carefully.  When  it  cannot  be  procured,  the  fluid  extract 
or  the  concentrated  infusion  of  coca  can  be  used  instead, 
applying  it  pure.  The  powder  recommended  for  acute 
rhinitis  (p.  69)  will  also  be  found  very  satisfactory,  its  modus 
operandi  being  the  same  as  in  that  affection.  When  the 
membrane  is  dry,  however,  the  sedative  steam  inhalations, 
described  on  page  61,  are  preferable. 


PLATE  n. 


PLATE   II. 

FIGURE  1. — Posterior  view  of  left  nasal  cavity  in  the  normal  state. 

2.— Lateral 
"        3. — Anterior 
"       4. — Rhinoscopic      "  "  t: 

P. — Rhinoscopic  "     mirror  slightly  turned. 

"       6. — Microscopical  section  of  the'  nasal  mucous  membrane  over  the  turbinated 
bones. 


a,  Superior  turbinated  hone. 

b,  Middle 

c,  Inferior  "  " 

d,  Eustachian  orifice. 

e,  Soft  palate. 
/,  Uvula. 

g,  Posterior  nasal  cavity. 


t,  Vestibule. 

_;',  Sphenoidal  sinus. 

k,  Frontal  " 

/,  Epithelium. 

n    Submucous  layer. 

n    Corpora  cavernosa. 

O,  Fossa  of  Rosenrauller. 


FIGURES  7  to  12. — Acute  rhinitis,  or  appearances  during  an  exacerbation  of  simple 
chronic  rhinitis.* 

FlGt'RE  11. — Rhinoscopic  view  of  hypertrophied   adenoid   tissue    in    the   posterior 
wall  of  the  naso-pharynx  during  an  acute  exacerbation. 


FIGURES   13    to    IK. — Hypertrophic   rhinitis;   anterior,    middle   and   posterior   hyper- 
trophies ;  fimbriated  adenoid  vegetations  in  the  naso-pharynx. 


*  Represented  as  seen  under  gas-light.     Under  natural  light,  the  red  color  is  much  lighter. 


Plate  II. 


'sajous,  P/nxit. 


If  HBuTLen  AeT LITH.PHIL*. 


HYPEHTEOPHIC   RHINITIS.  85 


HYPEBTROPHIC   RHINITIS. 

(Synonyms  : — Hypertrophy   of   the   Turbinated    Bones ;    Hypertrophic 
Nasal  Catarrh;  Hypertrophic  Ozoena.) 

Etiology. — Hypertrophy  of  the  nasal  mucous  membrane 
occurs,  in  the  majority  of  cases,  as  a  result  of  frequent 
attacks  of  acute  rhinitis,  or  as  a  complication  of  chronic 
rhinitis.  The  causes  of  these  affections  are  consequently 
the  initial  factors  in  the  production  of  the  hypertrophic 
changes,  to  which  may  be  added  improper  treatment,  such 
as  the  frequent  use  of  irritating  snuffs,  solutions  of  nitrate 
of  silver,  or  the  too  forcible  application  of  the  douche.  In 
some  cases,  it  seems  to  occur  idiopathically. 

Pathology. — While  in  uncomplicated  chronic  rhinitis  there 
is  already  a  certain  amount  of  thickening  and  induration  in 
the  epithelial  layer,  it  only  becomes  hypertrophic  rhinitis 
when  this  thickening  involves,  besides  the  epithelial  layer, 
the  other  elements  of  the  membrane.  When  the  chronic 
condition  has  existed  for  some  time,  the  infiltration,  stimu- 
lated now  and  then  by  an  inflammatory  exacerbation,,  finally 
becomes  organized,  and  connective  tissue  is  formed,  not  only 
in  the  mucous  membrane  proper,  but  in  the  sub-mucous 
layer,  the  "  corpora  cavernosa."  The  walls  of  the  venous 
sinuses  become  abnormally  thickened  and  rigid  through  this 
increase  of  new  connective  tissue,  and  cannot  collapse  as 
they  do  when  their  walls  are  normal,  but  remain  distended, 
thus  contributing  largely  to  the  general  increase  in  thick- 
ness. As  the  formation  of  connective  tissue  progresses,  new 
blood-vessels  are  formed,  and  all  the  normal  elements  of  the 
membrane  are  increased  in  proportion.  Its  thickness  can 
thus  be  multiplied  several  times,  but  as  the  new  formations 
are  not  evenly  distributed,  the  surface  is  irregular  in  out- 


8t)  DISEASES   OF   THE   ANTERIOE   NASAL   CAVITIES. 

line,  i.e.,  less  hypertrophied  in  some  localities  than  in 
others.  The  free  borders  of  the  middle  and  inferior  tur- 
binated  bones  are  the  most  frequent  sites  of  these  hyper- 
trophies, but  the  septum  is  also  occasionally  involved.  The 
venous  sinuses  of  the  posterior  portions  of  the  turbinated 
bones  being  much  larger  than  in  other  localities,  hyper- 
trophies are  frequently  found  there,  sometimes  sufficiently 
large  to  cause  complete  stenosis  of  the  posterior  nares. 
These  are  termed  posterior  hypertrophies,  in  contradis- 
tinction to  those  situated  in  the  anterior  portion  of  the  nasal 
cavity,  which  are  called  anterior  hypertrophies. 

Hypertrophic  changes  usually  progress  slowly,  many  years 
sometimes  elapsing  before  a  simple  chronic  rhinitis  will 
have  merged  into  the  hypertrophic  variety. 

Symptoms. — The  most  prominent  symptom  of  hyper- 
trophic rhinitis  is  the  interference  with  nasal  respiration. 
As  the  mucous  membrane  increases  in  thickness,  it  becomes 
much  more  sensitive  to  the  action  of  cold  and  other  irri- 
tants, arid  the  least  exposure  to  their  effects  causes  it  to 
become  suddenly  engorged,  the  swelling  induced  thereby 
being  added  to  that  already  existing  as  a  result  of  the 
hypertrophic  changes.  When  in  that  state  the  membrane  is 
sometimes  sufficiently  distended  to  occlude  the  nasal  cavity 
completely,  while  at  times,  the  hypertrophy  proper  is  so 
great  that  the  cavities  are  permanently  'occluded.  Any 
position  favoring  the  gravitation  of  the  blood  to  the  hyper- 
trophied parts  is  sufficient  in  the  majority  of  cases  to  cause 
their  distention;  lying  on  the  right  side,  for  instance,  will 
cause  occlusion  of  the  right  nostril,  tilting  the  head  forward 
will  cause  occlusion  of  both,  etc.,  while  suddenly  assuming 
the  erect  position,  or  any  startling  noise  or  stroke,  will  cause 
immediate  collapse  of  the  membrane  by  suddenly  stimu- 
lating the  sympathetic  system  and  inducing  sudden  con- 


HYPERTROPHIC  RHINITIS.  87 

traction  of  the  vessels.  When  the  occlusion  is  great  and 
constant,  the  patient  soon  acquires  the  habit  of  breathing 
through  the  mouth.  The  physiological  functions  of  the 
nose  not  being  performed,  the  air  reaches  the  other  portions 
of  the  respiratory  tract  without  having  been  purified  of  its 
irritating  elements,  dust,  etc.,  and  without  having  been 
supplied  with  moisture  and  heat.  Follicular  pharyngitis 
and  catarrhal  laryngitis  are,  for  that  reason,  frequent  ac- 
companiments of  the  affection,  while  in  persons  predisposed 
to  pulmonary  affections,  it  may  become  the  starting-point 
of  phthisis.  The  voice  acquires  a  peculiar  muffled  character, 
complicated  with  the  so-called  "nasal  twang,"  due  to  the 
partial  or  complete  absence  of  nasal  resonance,  as  the  case 
may  be.  The  face  sometimes  assumes  an  air  of  stupidity, 
owing  to  the  constantly  opened  mouth.  The  eyes  are  some- 
times reddened  and  watery,  on  account  of  the  occlusion  of 
the  lachrymal  canal.  Hearing  may  be  gravely  compromised, 
through  mechanical  impediment  of  posterior  growths,  the 
accumulation  of  discharges  in  the  mouth  of  the  Eustachian 
tubes,  or  inflammatory  infiltration  of  their  mucous  lining. 
The  distended  membrane  preventing  the  access  of  odor- 
iferous bodies  to  the  olfactory  region,  the  sense  of  smell 
may  be  completely  absent,  while  that  of  taste  may  be 
sensibly  diminished  on  account  of  its  intimate  relation  with 
the  former.  Periodical  headaches  in  the  frontal  and  supra- 
orbital  regions  are  often  complained  of. 

There  is  usually  considerable  increase  in  the  amount  of 
nasal  secretion.  Quantities  of  thick  viscid  mucus  accumulate 
in  the  posterior  nasal  cavity,  and  adhering  there,  force  the 
patient  to  hawk  and  scrape  until  the  discharges  are  drawn 
into  the  mouth  and  expectorated.  These  do  not  originate 
only  in  the  anterior  cavities,  but  also  in  the  pharyngeal 
vault,  the  glands  of  which  are  over-stimulated.  When  the 


88  DISEASES   OF  THE  ANTERIOR  NASAL   CAVITIES. 

hypertrophy  is  great,  the  impediment  to  their  free  egress 
causes  them  to  accumulate  in  the  sinuosities  of  the  pas- 
sages, to  form  there,  through  the  evaporation  of  their  watery 
constituents,  fetid  masses  or  scabs,  generally  of  a  greenish- 
brown  color.  The  breath  is  consequently  very  offensive 
at  times,  this  being  especially  the  case  in  persons  of  a 
strumous  diathesis.  The  frequent  contact  of  these  irritating 
discharges  with  the  pharynx  on  their  passage  downward, 
adds  another  cause  for  pharyngeal  inflammation  to  the  pre- 
ceding, while  the  constant  hawking  keeps  up  an  active 
congestion  of  the  soft  palate,  which  soon  induces  elongation 
of  both  it  and  the  uvula,  adding  to  the  original  affection 
new  causes  for  active  symptoms.  The  larynx  is  also  ex- 
posed to  the  action  of  what  discharges  are  not  expectorated, 
by  acting  as  a  receptacle  for  them,  owing  to  its  proximity 
to  the  pharyngeal  wall.  The  secretions  run  down  along  the 
latter  and  meeting  the  posterior  laryngeal  border,  either 
pass  into  the  cavity  of  the  larynx  between  the  arytenoids 
or  are  swallowed.  In  order  to  clear  the  throat  of  the  em- 
barrassing agent,  hemming  is  resorted  to,  which,  added  to 
the  hawking  and  scraping  already  described,  make  the 
sufferer  an  unpleasant  companion.  The  catarrhal  laryngitis 
excited  by  oral  breathing  is  thus  aggravated,  cough  super- 
venes, and  this,  in  conjunction  with  what  muco-purulent 
discharges  are  expectorated,  frequently  leads  the  patient  to 
believe  that  he  is  phthisical.  The  diminished  lumen  of  the 
larynx,  when  highly  congested,  may  give  rise  to  asthmatic 
symptoms,  and  these,  combined  with  the  difficulty  ex- 
perienced in  breathing  through  the  nose,  cause  the  patient 
great  annoyance,  especially  at  night  and  upon  exertion. 
Reflex  asthma  is  also  occasionally  present  as  a  result  of  the 
intra-nasal  pressure. 

Upon  examining  the  parts  anteriorly,  the  membrane  will 


HYPERTROPHIC   RHINITIS.  80 

appear  normal  in  color  in  some  cases,  and  red  in  others, 
according  to  the  intensity  of  the  inflammatory  process.  The 
lumen  of  the  cavity  examined  being  decreased  in  propor- 
tion to  the  degree  of  hypertrophy,  it  may  be  but  slightly 
encroached  upon  by  the  thickened  membrane,  or  to  a  degree 
sufficient  to  cause  complete  stenosis.  The  surface  of  the 
inferior  turbinated  bone  is  usually  the  most  prominent  por- 
tion, and  bulges  out  sufficiently,  sometimes,  to  compress  the 
septum,  frequently  giving  rise  to  ulcerations  and  slight 
epistaxis ;  ordinarily  it  only  approximates  the  latter,  and 
its  edge  rests  against  the  floor  of  the  cavity.  It  yields 
upon  pressure  with  a  probe,  to  suddenly  recover  its  former 
shape,  differing  in  this  from  simple  chronic  rhinitis,  where 
the  resumption  of  shape  is  sluggish.  In  the  former  case, 
the  newly-organized  tissue  forms  an  elastic  bed  which  im- 
mediately recoils,  while  in  the  latter,  the  pressure  merely 
displaces  a  certain  amount  of  infiltration  which  is  slower 
in  returning  to  its  former  position.  The  middle  turbinated, 
when  much  hypertrophied,  stands  out  more  horizontally, 
and  as  its  longitudinal  axis  slants  from  before  backwards 
more  than  the  inferior,  the  under  surface  of  its  free  edge 
is  usually  seen  resting  against  the  septum,  and  appearing 
to  form  part  of  it. 

The  septum  often  takes  part  in  the  hypertrophic  process, 
its  mucous  membrane  presenting  the  same  appearances  in 
color  as  that  over  the  turbinated  bones.  Whether  located 
on  the  septum  or  over  the  latter,  the  thickening  is  not 
evenly  distributed,  occurring  in  some  cases  in  irregular 
prominences,  and  in  others  as  thick,  cushion-like  protuber- 
ances, involving  the  whole  length  of  the  affected  portion. 
The  turgescence  differs  from  that  of  simple  chronic  rhinitis 
by  its  permanency,  occurring  in  the  latter  affection  only 
during  exacerbations.  The  turbinated  bones  proper  are 


90  DISEASES   OF   THE   ANTERIOR   NASAL   CAVITIES. 

sometimes  hypertrophied,  their  conformation  being  easily 
determined  by  means  of  a  probe. 

Hypertrophies  involving  the  posterior  ends  of  the  tur- 
binated  bones  and  the  posterior  portion  of  the  septum, 
can  only  be  seen  with  the  aid  of  the  rhinoscopic  mirror. 
They  present  appearances  altogether  different  from  those 
just  described,  not  only  in  shape  but  in  color.  There  are 
two  varieties,  the  ivliite  and  the  purple.  The  white  hy- 
pertrophies, by  far  the  more  common  of  the  two,  are  usually 
rounded,  and  present  an  irregular  surface  much  like  that 
of  a  raspberry.  They  protrude  more  or  less  into  the 
posterior  cavity,  frequently  compromising  mechanically  the 
openings  of  the  Eustachian  tubes,  which  are  immediately 
behind,  on  each  side.  The  inferior  turbinated  bone  is  most 
frequently  their  seat,  but  they  are  also  often  present  at  the 
posterior  portion  of  the  middle  turbinated,  and  on  each  side 
of  the  septum  near  its  posterior  border,  bulging  out  in  the 
direction  of  the  turbinate  hypertrophies,  and  assisting  in 
the  production  of  stenosis.  The  second  variety,  purple  in 
color  and  much  softer  to  the  touch,  are  rarely  met  with, 
and  occur  principally  on  the  inferior  turbinated  body.  They 
bleed  easily,  sometimes  upon  the  least  contact  of  an  in- 
strument. 

The  vault  of  the  pharynx  is  often  implicated  in  the  affec- 
tion, being  merely  congested  in  some  cases,  while  in  other 
cases  it  is  the  seat  of  pathological  changes  so  important  as  to 
merit  special  consideration  in  another  portion  of  this  volume. 

Prognosis. — Occurring  in  a  subject  in  whom  no  faulty 
diathesis  exists,  hypertrophic  rhinitis,  so  far  as  the  local 
condition  is  concerned,  does  not  tend  to  assume  a  danger- 
ous character.  When  it  has  reached  a  certain  limit,  amount- 
ing to  complete  nasal  occlusion  in  some,  and  to  hardly 
perceptible  interference  with  nasal  respiration  in  others,  it 


HYFERTKOPHIC   RHINITIS.  91 

either  remains  in  that  state  until  the  patient  has  passed 
middle  life,  when  the  hypertrophied  membrane,  influenced 
to  a  greater  degree  than  the  system  at  large  by  the  general 
atrophic  process,  gradually  recedes  to  its  normal  state,  or 
merges  into  atrophic  rhinitis,  which  will  be  described  under 
the  next  heading.  When  the  degree  of  hypertrophy  has 
been  great,  a  certain  amount  of  nasal  obstruction  sometimes 
remains,  the  bones  proper  having  taken  part  in  the  hyper- 
trophic  process  and  remained  hypertrophied.  Hearing  is 
frequently  compromised,  and  sometimes  lost.  The  sense  of 
smell  is  generally  impaired,  resulting  occasionally  in  com- 
plete anosmia,  and  involving,  in  the  majority  of  cases,  the 
sense  of  taste.  Pharyngitis  sicca,  occurring  as  a  result  of 
the  oral  breathing,  and  the  contact  of  the  pharynx  with 
the  discharges,  is  a  frequent  sequel.  The  affection  is  the 
origin  of  a  vast  majority  of  the  many  cases  of  catarrhal 
laryngitis  we  are  called  upon  to  treat  during  the  winter 
months,  and  it  is  but  reasonable  to  conclude  that  in  an 
individual  predisposed  to  pulmonary  consumption,  it  may 
act  as  an  exciting  cause.  Emphysema  is  frequently  ob- 
served when  the  nasal  obstruction  is  of  long  standing. 

Since  the  introduction  of  surgical  measures  in  the  treat- 
ment of  hypertrophic  rhinitis,  its  prognosis  as  to  recovery 
has  become  very  favorable.  When  medicinal  treatment  was 
solely  relied  upon,  the  benefit  it  procured  was  but  temporary, 
the  organized  state  of  the  new  cellular  tissue  elements 
rendering  their  absorption  hardly  to  be  expected. 

Treatment. — Clinical  experience  has  demonstrated  that 
when  the  now  connective  tissue  elements  characterizing  the 
affection  are  yet  undergoing  formation,  their  absorption  can 
be  induced  by  medicinal  treatment  or  by  pressure,  but  that 
when  these  tissues  have  become  firmly  organized,  surgical 
interference  can  alone  produce  permanent  results.  A  clear 


92  DISEASES    OF    THE    ANTEEIOK   NASAL   CAVITIES. 

differential  diagnosis  between  these  two  conditions  is  con- 
sequently of  the  greatest  importance  before  instituting  treat- 
ment. 

Whether  hypertrophic  rhinitis  occur  as  a  result  of  simple 
chronic  rhinitis,  or  from  any  other  cause,  its  early  pathology 
and  initial  symptoms  are  so  allied  with  those  of  the  latter 
affection  as  to  render  any  differentiation  between  them  ex- 
ceedingly difficult,  if  not  impossible.  As  the  hypertrophic 
process  advances,  however,  the  two  affections  gradually  as- 
sume distinct  positions,  not  only  in  pathology,  but  in  their 
subjective  and  objective  symptoms.  The  differential  diag- 
nosis consequently  resolves  itself  into  determining  whether 
the  pathological  condition  is  as  yet  in  that  state  in  which  it 
cannot  be  distinguished  from  the  simple  chronic  condition, 
in  which  case  the  treatment  described  for  that  affection 
would  be  indicated,  or  whether  the  pathological  changes 
have  so  far  progressed  as  to  make  the  diagnosis  hyper- 
trophic rhinitis,  rendering  surgical  procedures  necessary.  As 
already  explained,  the  resiliency  of  the  redundant  portions, 
when  pressed  upon,  furnishes  means  by  which  the  presence 
of  hypertrophic  tissue  can  be  estimated,  while  the  degree  of 
hypertrophy  can  be  ascertained  by  inducing  contraction  of 
the  turgescent  areas,  by  a  local  application  of  a  four  per 
cent,  solution  of  hydrochlorate  of  cocaine.  The  membrane, 
completely  emptied  of  its  fluids,  cannot  contract  more  than 
the  organized  elements  in  its  layers  will  allow,  and  its  actual 
thickness  can  then  easily  be  determined.  In  uncomplicated 
chronic  rhinitis  the  contraction  is  almost  complete,  the  thick- 
ening in  the  sub-epithelial  layer  not  being  sufficient  to  cause 
any  appreciable  difference  in  the  appearance  of  the  mem- 
brane. Its  surface  is  smooth  and  uniform,  the  conformation 
of  the  bone  beneath  being  often  descernible.  As  soon  as 
sufficient  hypertrophic  tissue  has  formed  to  become  notice- 


HYPERTROPHIC   RHINITIS.  93 

able,  however,  the  smoothness  and  uniformity  are  lost,  and 
irregular  prominences  appear,  indicating  the  localities  in 
which  the  hypertrophic  process  is  most  advanced,  and  where 
surgical  measures  will  be  most  effective. 

The  presence  of  hypertrophic  rhinitis  having  been  recog- 
nized, a  successful  result  can  only  be  obtained  by  resorting 
to  a  treatment  calculated  to  destroy  a  sufficient  quantity  of 
the  redundant  tissue,  to  insure,  with  the  assistance  of  the 
resulting  inflammation  and  the  subsequent  cicatricial  con- 
traction, its  complete  reduction.  Cleanliness,  however,  as  in 
the  other  forms  of  rhinitis,  is  an  essential  part  of  the  treat- 
ment, but  great  care  should  be  practiced  in  conducting  the 
cleansing  measures,  lest  too  much  •  mechanical  irritation  or 
stimulation  encourage  the  morbid  process.  When  the  degree 
of  hypertrophy  is  moderate,  and  the  discharges  are  soft,  sat- 
isfactory ablution  of  the  parts  can  be  conducted  through 
the  anterior  nares.  The  atomizer  serves  the  best  for  the 
purpose,  all  other  methods,  even  inhaling  liquids  from  the 
palm  of  the  hand,  involving  undesirable  mechanical  irrita- 
tion. When  the  hypertrophic  process  has  so  far  progressed 
as  to  cause  marked  narrowing  of  the  cavity,  the  spray  will 
not  reach  the  mucous  surface  behind  the  bulging  portions, 
and  the  solution  must  be  applied  posteriorly.  In  these  cases, 
however,  the  discharges  are  generally  considerable,  and  they 
agglomerate  into  thick  masses,  which  adhere  with  so  much 
tenacity  that  the  cavities  cannot  be  thoroughly  cleansed 
unless  more  mechanical  power  accompany  the  stream  than 
is  the  case  when  the  atomizer  is  used.  A  very  satisfactory 
instrument  for  the  purpose  is  Hall's  bulb  syringe  (Fig.  10). 
It's  stream  can  be  so  nicely  regulated  that  any  degree  of 
force  can  be  employed,  while  any  quantity  of  fluid  can  be 
injected  at  a  given  time.  This  becomes  of  great  importance 
when  the  limited  space  remaining  free  in  the  anterior  nasal 


DISEASES    OF    THE    ANTERIOR   NASAL    CAVITIES. 

cavity  for  the  egress  of  the  liquid  is  remembered.  The 
glass  nozzle,  shown  in  Fig.  16,  cannot  be  used,  however,  the 
volume  of  liquid  it  allows  to  pass  being  too  considerable. 
That  represented  in  the  cut  below,  a  hard  rubber  tube  with 
end  turned  upward  and  perforated  with  minute  holes,  allows 
the  solution  to  flow  in  numerous  little  streamlets,  which 


Fig.  30. 


The  nozzle  for  posterior  irrigation  in  position. 

bathe  the  parts  thoroughly  without  causing  a  too  rapid  ac- 
cumulation of  fluid.  The  directions  given  for  post-nasal 
douching  should  be  carefully  followed  by  the  patient. 

The  cleansing  solution  recommended  in  simple  chronic 
rhinitis  can  also  be  used  in  this  affection.  It  is  very  pleasant 
to  the  patient,  effective  in  removing  accumulated  discharges, 
and  does  not  irritate  the  parts,  when  used  lukewarm  (100°  F.). 
It  is  best  prescribed  prepared  in  tablets,  one  of  these  con- 


HYPERTROPHIC   RHINITIS.  95 

taining  twenty  grains  of  each  of  the  three  ingredients,  and 
forming  the  exact  proportion  for  one  pint  of  water.  The 
solution  formed  possesses,  besides  cleansing  and  medicinal 
properties,  the  proper  specific  gravity.  When  the  breath  is 
very  offensive,  three  grains  of  permanganate  of  potassium 
may  be  added.  A  complete  list  of  these  tablets  will  be 
found  in  the  Appendix. 

The  means  at  our  disposal  for  the  reduction  of  the  hyper- 
trophied  mucous  membrane  differ  according  to  the  degree 
of  hypertrophy,  and  consist  in  the  use  of  caustic  acids, 
galvano-cautery,  the  galvano-caustic  snare,  and  the  cold-wire 
snare. 

The  three  acids  usually  employed  are  the  nitric,  chromic 
and  glacial  acetic.  The  first  is  by  far  the  most  powerful, 
and  its  action  can  only  be  limited  by  using  it  in  very  small 
quantities  at  a  time.  If  too  much  is  applied  to  the  mem- 
brane, deep-seated  ulceration  may  ensue,  and  give  rise  to 
much  annoyance. 

As  already  explained,  a  very  thin  probe  should  be  used, 
with  a  film  of  cotton  wrapped  around  the  tip.  Being  dipped 
in  the  acid,  and  applied  against  a  blotter  to  prevent  dripping, 
the  cotton  pledget  is  applied  to  the  most  prominent  portion 
of  the  membrane,  limiting  the  application  to  an  area  about 
the  size  of  a  small  pea.  A  sharp  pain  is  felt,  unless  the 
membrane  be  previously  anaesthetized  with  cocaine,  or  the 
acid  contain  a  sufficient  quantity  of  the  latter  in  solution. 
When  the  cocaine  is  not  used,  however,  the  pain  can  be 
quickly  arrested  by  applying  with  the  atomizer,  a  saturated 
solution  of  bicarbonate  of  sodium,  which  will  also  limit  the 
penetration  of  the  acid.  During  the  day,  the  patient  ex- 
periences a  sensation  of  fullness  in  the  nostril  cauterized. 
This,  however,  only  lasts  a  few  hours,  and  in  some  cases 
does  not  occur  at  all.  The  next  day,  shreds  of  the  destroyed 


96  DISEASES   OF   THE   ANTERIOR   NASAL   CAVITIES. 

mucous  membrane  are  discharged,  and  a  feeling  of  relief 
is  at  once  experienced.  This  continues  until  all  the  cauter- 
ized tissue  has  been  thrown  off,  leaving  a  groove  to  mark 
the  seat  of  the  exfoliation.  This  groove  gradually  fills  up, 
not  by  reproduction  of  tissue,  but  by  a  displacement,  as  it 
were,  of  the  surrounding  superficial  stratum,  which  con- 
tracts, thereby  constricting  the  parts  beneath.  This  process 
requires  for  its  completion  about  a  week.  A  great  advan- 
tage possessed  by  nitric  acid  is  that  it  requires  but  one  or 
two  applications  to  contract  markedly  the  hypertrophied 
membrane.  At  least  two  weeks  should  elapse  between  each 
application.  An  earlier  renewal  of  the  cauterization  on  the 
same  spot  might  give  rise  to  serious  inflammation,  and 
perhaps  erysipelas. 

In  inexperienced  hands,  glacial  acetic  acid  is  a  much  safer 
agent,  but  requires  a  greater  number  of  applications  to 
produce  the  same  effect.  The  instrument  shown  below, 
devised  by  Dr.  Bosworth,  of  New  York,  is  very  convenient 
for  its  application.  Its  end  is  flattened,  and  when  wrapped 

Fig.  31. 


Bosworth' s  probe. 


with  cotton,  presents  a  comparatively  wide  surface,  while  at 
the.  same  time  it  can  be  introduced  into  the  narrowest 
cavity.  It  is  dipped  into  the  acid  if  both  sides  of  the 
cavity  are  to  be  treated,  that  is,  if  there  is  septal  hyper- 
trophy besides  the  turbinate,  and  dropped  on  one  side  if  the 
hypertropy  be  limited  to  the  latter.  The  vestibule  being 
dilated  and  illuminated,  the  charged  end  is  passed  into  the 
nasal  cavity  along  the  free  edge  of  the  hypertrophied  tur- 
binated  body,  or  applied  to  the  septal  growth,  as  the 


HYPERTROPHIC   RHINITIS.  97 

case  may  be.  The  pain  induced  is  much  less  severe  than 
when  nitric  acid  is  used,  but  again  the  amount  of  tissue 
destroyed  is  much  more  limited.  Seven  or  eight  applica- 
tions at  a  week's  interval  are  necessary  to  produce  the 
effect  of  one  application  of  nitric  acid,  but  the  improvement 
is  gradual  and  steady,  and  if  care  be  taken  to  touch  the 
same  spot  each  time,  in  order  to  as  much  as  possible  avoid 
the  destruction  of  the  ciliated  epithelium,  not  only  will  the 
stenosis  be  remedied,  but  the  physiological  functions  of  the 
membrane  proper  will  be  preserved. 

Chromic  acid  is  highly  recommended  by  several  eminent 
specialists.  The  most  convenient  method  for  its  employ- 
ment is  to  heat  the  tip  of  an  ordinary  probe  and  to  apply 
it  against  one  of  the  acicular  crystals  of  the  acid.  Care 
should  be  taken  not  to  overheat  the  instrument,  lest  decom- 
position of  the  acid  occur.  Enough  adheres  for  two  appli- 
cations. Chromic  acid  gives  rise  to  little  or  no  pain,  and  is 
very  effective,  but  systemic  intoxication  is  liable  to  occur 
if  too  great  a  quantity  is  used  at  one  sitting.  Its  applica- 
tion should  consequently  be  limited  to  a  small  area,  and 
renewed  from  two  to  five  times  as  the  case  may  be.  As 
with  nitric  and  glacial  acetic  acid,  any  excess  can  be 
neutralized  by  applying  over  the  cauterized  surface,  a  sat- 
urated solution  of  bicarbonate  of  sodium. 

(ralvano-cautery  possesses  many  advantages  over  any 
method  employed  for  the  reduction  of  hypertrophies.  Its 
application  gives  rise  to  but  little  pain,  and  the  local  inflam- 
mation following  its  use  is  so  limited,  that  it  is  hardly  per- 
ceived by  the  patient  in  the  great  majority  of  cases.  A 
number  of  excellent  batteries  are  at  our  disposal,  among 
which  may  be  mentioned  Setter's,  of  Philadelphia,  and  Pif- 
fard's,  of  New  York.  The  former  is  the  more  convenient 
of  the  two  instruments,  and  was  used  by  me  until  lately, 


98 


DISEASES   OF   THE   ANTEEIOK   NASAL   CAVITIES. 


when,  having  replaced  cold  wire  snaring  by  galvano-caustic 
snaring  in  my  practice,  I  found  it  necessary  to  devise  an 
apparatus  capable  of  furnishing  a  greater  quantity  of  elec- 
tricity when  this  was  required,  without  increasing  the  bulk 
of  the  instrument.  Fig.  32  represents  the  battery  as  the 
plates  are  being  immersed,  the  foot  of  the  operator  having 
depressed  the  pedal  and  caused  the  plates  to  descend  into 
the  glass  jar  containing  the  fluid.  The  degree  of  heat 
can  thus  be  easily  regulated  at  will  by  raising  or  lowering 

Fig.  32. 


Author's  gal vano- cautery  battery. 

the  foot,  an  advantage  introduced  by  Seller's  battery.  The 
foot-motion,  however,  is  much  more  limited  than  in  the 
latter,  and  does  not  necessitate  raising  the  heel  from  the 
ground.  The  body  being  thus  well  supported,  the  steadiness 
of  the  hand  is  not  compromised.  An  important  feature  in 
its  construction  is  that  the  mechanism  for  lowering  and 
raising  the  plates  is  wooden,  and  is,  therefore,  not  influenced 
by  the  acid  fumes.  The  plates  being  corrugated,  as  suggested 
by  my  friend,  Mr.  Arthur  Kit-son,  electrical  engineer,  more 


HYPERTROPHIC   RHINITIS.  99 

surface  is  exposed  to  the  fluid,  and  a  slight  to-and-fro 
motion,  which  can  be  communicated  to  the  plates  from  the 
outside  of  the  case,  causes  them  to  agitate  the  fluid  to  such 
a  degree  as  to  liberate  the  hydrogen  bubbles  deposited  on 
their  surface.  Polarization  can  thus  be  prevented  to  a  marked 
degree.  Notwithstanding  its  small  size  (being  only  fifteen 
inches  wide,  fourteen  high,  and  nine  deep),  this  battery  can 
heat  from  the  smallest  platinum  point  to  a  thick  loop  of  the 
same  metal. 

F'g   33- 

(/    'v^^^sHI^HH^^HH^^^^^IBB^BIExSy'*1^^  ^  ^^ )\_ 


Author's  universal  handle. 


a,  handle;  a',  central  section  of  handle;  6,  side  view  of  clasp;  b',  full  view  of  clasp;  c,  finger-lever;  d. 
electrode  for  flat  applications;  e,  electrode  for  linear  incisions;  f,  cautery  snare  for  horizontal  growths;  /', 
the  latter,  seen  from  behind;  g,  cautery  soare  for  perpendicular  growths;  A,  cold-wire  snare;  h',  the  latter, 
seen  from  above. 

Some  years  ago  Dr.  Shurly,  of  Detroit,  devised  an  in- 
genious handle  with  a  set  of  electrodes,  for  galvano-caustic 
applications  to  the  nose  and  pharynx.  For  my  own  use,  I 
had  constructed  the  handle  shown  in  Fig.  33,  preserving 
the  convenient  shape  of  Dr.  Shurly's  instrument  and  the 
relative  angle  of  the  electrodes.  The  mechanism,  however, 


100  DISEASES    OF   THE   ANTERIOR   NASAL   CAVITIES. 

is  different,  and  enables  it  to  be  used  not  only  for  holding 
electrodes,  but  for  either  cold  or  galvano-caustic  snaring, 
and  for  a  number  of  purposes  which  will  be  described  under 
the  headings  of  the  diseases  in  which  it  is  applicable. 

The  handle  «,  «',  is  made  of  hard  rubber  and  hollow 
throughout.  A  metallic  rod  or  conductor  is  fastened  to 
each  side  of  its  interior,  extending  from  the  middle  of  the 
handle  to  within  one-quarter  inch  of  its  extremity,  each 
end  serving  to  secure  one  of  the  posts  of  the  canula  used, 
when  the  latter  is  inserted  as  shown  in  the  cut.  These 
posts  being  notched,  are  maintained  in  position  by  a  cor- 
responding tooth  at  the  end  of  each  conductor,  the  latter 
possessing  enough  spring  to  insure  perfect  hold.  By  press- 
ing on  a  button  situated  on  each  side  of  the  handle,  near 
its  extremity,  the  ends  of  the  conductors  are  approximated, 
thus  disengaging  the  teeth  from  the  notches,  and  allowing 
the  canula  to  be  withdrawn.  When  the  instrument  is  to 
be  used  for  snaring  purposes,  the  posts  of  the  canula  em- 
ployed are  adjusted  and  held  in  the  same  manner.  The  wire 
having  been  passed  through  the  cylinders  of  the  electrode, 
or  through  the  tube  of  the  cold-wire  snare,  its  two  ends  are 
attached  to  the  end  of  a  movable  vulcanized  strip,  which 
protrudes  somewhat,  and  can  slide  up  and  down  in  the  interior 
of  the  handle.  Traction  can  then  be  induced  by  turning  the 
milled  nut  at  the  posterior  extremity  of  the  instrument,  which 
revolves  around  a  threaded  screw  fastened  to  the  rear  end  of 
the  hard-rubber  strip,  or  by  pressing  upon  the  finger-lever  c, 
the  arm  of  which  pushes  the  strip  backward  by  working  in  a 
ratchet  screwed  to  its  upper  surface. 

For  cold  snaring,  what  is  known  as  No.  5  piano  wire  is  the 
most  satisfactory,  possessing  the  required  tensile  strength  and 
elasticity.  For  galvano-caustic  snaring,  platinum  wire  must 
be  employed,  of  a  thickness  proportionate  with  the  degree  of 
resistance  to  be  met  with. 


HYPERTROPHIC   RHINITIS.  101 

The  handle  is  connected  with  the  battery  cord  by  means 
of  a  clasp,  b  and  &',  the  two  arms  of  which  are  furnished  at 
their  extremity  with  right-angle  posts.  These  rest  against  the 
conductors  by  passing  through  holes  penetrating  the  sides  of 
the  handle  on  each  side.  Although  grasping  the  latter  firmly, 
through  the  action  of  a  strong  spring-hinge  which  unites 
the  arms  of  the  clasp,  one  of  the  posts  is  not  in  perfect  con- 
tact with  the  conductor  on  the  same  side  (this  being  pre- 
vented by  a  short  spring  between  the  arm  and  the  handle), 
but  the  contact  becomes  perfect  by  slight  pressure  of  the 
thumb  when  the  instrument  is  held,  and  the  circuit  can 
thus  be  closed  or  opened  at  will,  leaving  the  index  finger 

Fig-  34- 


Allen's  nasal  specula. 

free,  to  work  the  finger-lever  c  if  required.  When  the  circuit 
is  closed  the  current  passes  through  the  clasp  to  the  con- 
ductors, which  in  turn  transmit  it  to  the  canula.  To  disengage 
the  clasp  from  the  handle,  the  lower  ends  of  the  arms  of 
the  former  are  approximated,  thus  causing  the  upper  sec- 
tions to  open  out. 

When  the  hypertrophy  is  situated  anteriorly  and  is  not 
very  large,  a  linear  incision,  made  with  knife  e,  is  sometimes 
sufficient  to  reduce  it  completely.  In  order  to  obtain  the 
best  effect  from  the  cauterization,  the  platinum  loop  must 
be  introduced  glowing,  and  the  margin  of  the  nostril  must 
therefore  be  protected.  Dr.  Harrison  Allen's  nasal  specu- 
lum is  very  efficient  for  the  purpose,  and,  several  sizes  being 
procurable,  a  suitable  instrument  can  be  employed  in  each 


102  DISEASES    OF   THE    ANTEEIOR   NASAL    CAVITIES. 

case.  It  should  be  inserted  and  held  with  the  left  hand  in 
such  a  manner  that  the  prominence  to  be  treated  will  ap- 
pear opposite  the  small  opening.  The  knife  is  then  entered 
into  the  speculum,  and  the  circuit  is  closed  just  as  the 
platinum  loop  has  reached  beyond  its  external  or  wide  open- 
ing. Holding  it  there  an  instant,  until  the  proper  heat  is 
attained,  the  instrument  is  pushed  forward  so  as  to  cause 
its  sharp  edge  to  penetrate  the  centre  of  the  prominence, 
and  advanced  until  an  incision  of  the  desired  length  has 
been  made.  The  circuit  is  then*  broken,  and  the  instrument 
is  withdrawn  cold.  As  a  result,  the  different  layers  of  the 
membrane  are  severed,  including  the  dilated  blood-vessels 
and  sinuses,  and  cicatricial  bands  are  formed  which  cause 
the  contraction  to  involve  its  entire  thickness. 

An  important  matter  in  connection  with  this  operation 
is  the  proper  regulation  of  the  heat.  When  the  platinum 
point  is  not  sufficiently  hot — black  heat — it  causes  great 
pain.  When  it  is  too  hot — white  heat — it  causes  profuse  hem- 
orrhage. Cherry  heat  is  hardly  felt  by  the  patient,  causes  no 
bleeding,  and  is  more  effective  than  either  of  the  two  others. 

Some  specialists  employ  a  shield  to  protect  the  membrane 
of  the  septum ;  I  have  never  found  such  an  instrument 
necessary,  and  merely  apply  a  little  vaseline  over  its  sur- 
face, to  avoid  the  sensation  of  heat  which  the  radiation  from 
the  hot  metal  might  occasion.  Should  the  septal  membrane 
be  accidentally  touched,  the  burn  heals  without  trouble. 
Such  is  not  the  case,  however,  if  the  skin  around  the  mar- 
gin of  the  nostril  is  singed ;  the  pain  is  not  only  very  severe, 
but  lasting. 

The  after-effects  of  an  application  of  galvano-cautery,  per- 
formed in  this  manner,  are  almost  nil.  Occasionally,  slight 
inflammation  occurs,  the  membrane  swells,  and  slight  shoot- 
ing pains  are  felt  along  the  distribution  of  the  fifth  pair,  es- 


HYPERTROPHIC   RHINITIS.  103 

pecially  the  superior  maxillary  branches.  After  a  few  hours, 
however,  these  symptoms  disappear  and  the  membrane  re- 
turns to  its  former  state.  Some  cases  have  been  reported 
in  which  violent  inflammation  occurred  after  galvano-caustic 
applications.  I  have  never  met  with  such  a  misfortune, 
the  only  untoward  effect  noticed  being  a  momentary  poly- 
poid swelling  of  the  membrane  of  the  middle  turbinated 
bone,  occurring,  strange  to  say,  in  the  same  locality  in  three 
patients.  The  slight  inflammation  induced  by  galvano-caustic 
or  acid  applications,  may  cause  adhesion  of  the  cauterized 
area  to  the  membrane  of  the  septum,  and  thus  obstruct  the 
cavity.  This  should  be  guarded  against  by  seeing  the 


V 


SNOWDCN 
Jarvis'  transfixing  needles. 


patient  every  other  day  while  the  inflammatory  process  is 
progressing,  pledgets  of  cotton  being  interposed  between  the 
surfaces  to  prevent  their  agglutination,  if  necessary.  If  a 
second  application  should  be  deemed  advisable,  a  week,  at 
least,  should  elapse  before  making  it,  in  order  to  allow  the 
local  inflammation  to  subside. 

When  the  hypertrophies  are  very  large,  the  contraction 
resulting  from  simple  applications  is  not  sufficiently  effective. 
A  portion  of  the  membrane  must  be  removed.  For  this 
purpose,  Dr.  Jarvis'  transfixing  needles  are  very  useful.  One 
of  these  being  passed  through  the  growth  as  shown  in  Fig. 
36,  the  cautery  loop  /  (Fig.  33)  is  passed  into  the  nasal  cavity 
over  the  handle  of  the  needle,  and  over  its  point  as  it  pro- 


104 


DISEASES    OF   THE   ANTEKIOE   NASAL   CAVITIES. 


trades  from  the  surface.  The  wire  being  then  tightened 
around  the  growth,  by  depressing  the  finger-lever,  the  cir- 
cuit is  closed,  and  a  few  turns  of  the  milled  nut  at  the  end 
of  the  handle  will  cause  separation  of  the  transfixed  portion 
of  the  hypertrophied  membrane  from  its  base.  The  pain 

Fig.  36. 


The  needle  and  loop  in  position. 

experienced  is  usually  very  slight,  and  the  wound  heals  with- 
out trouble. 

This  operation  may  also  be  performed  in  the  manner  sug- 
gested by  Dr.  Harrison  Allen,  which  consists  in  applying  the 
heated  loop  against  the  side  of  the  growth,  and  allowing  it 
to  burn  its  way  into  it,  until  a  portion  of  the  mass  can  be 
grasped,  when  the  loop  may  be  narrowed  and  the  portion 
removed.  Dr.  Allen  employs  for  this  and  his  other  galvano- 
caustic  snaring  operations,  the  ingenious  instrument  shown 
in  Fig.  37. 

The  body  of  the  instrument  consists  of  a  slotted  aluminum 
barrel  containing  a  screw  of  equal  length.  The  latter  is  con- 
nected with  a  vulcanite  "  carriage "  which  moves  freely  over 


HYPEIITHOPHIC   EHINITIS.  105 

the  barrel,  and  serves  for  the  attachment  of  the  wires  and 
battery  cords.  A  milled  nut  at  the  end  of  the  screw  causes 
the  latter  to  descend  when  turned,  and  the  loop  is  thus  drawn 
home.  A  novel  feature  introduced  by  this  instrument  is  the 
fact  that  the  platinum  wire  is  covered  with  a  uniform  coat  of 

Fig-  37- 


Allen's  galvano-eautery  snare. 

copper,  excepting  alone  the  portion  forming  the  loop,  which 
is  bare.  The  current  can  in  this  manner  be  transmitted  along 
the  wires  by  means  of  the  copper  layer. 

When  the  surgeon  is  not  possessed  of  galvano-cautery 
instruments,  the  same  operation  can  be  performed  with  the 
cold-wire  snare  shown  in  Fig.  38,  a  modification  of  an  in- 
strument also  invented  by  Dr.  Jarvis. 

To  arm  it  for  use,  a  small  piece  of  wire  two  or  three 
inches  in  length,  according  to  the  size  of  the  tumor,  is 
doubled  into  a  loop,  and  the  ends  are  passed  through  the 
eye  of  the  rod  until  they  protrude  a  quarter  of  an  inch. 
Traction  being  then  caused  by  turning  the  milled  nut,  the 
end  of  the  rod,  which  otherwise  projects  beyond  the  ex- 
tremity of  the  tube  a  short  distance,  disappears  in  the 
latter,  doubling  the  wire  ends  on  the  loop.  The  latter  is 
then  firmly  held  and  ready  for  use.  Being  passed  over 
needle  transfixing  the  membrane,  the  nut  is  turned  until 
the  tumor  is  firmly  held  in  the  grasp  of  the  loop.  Care 
must  now  be  taken  to  not  cause  it  to  cut  through  too 
hastily,  lest  severe  hemorrhage  occur.  Twenty  to  thirty 
minutes,  at  least,  should  be  employed  to  gradually  pene- 


10G 


DISEASES   OF   THE   ANTERIOR   NASAL   CAVITIES- 


trate  the  growth,  turning  the  nut  once  in  a  while.  If  per- 
38  formed  in  this  way  the  operation  Fi?  33 
is  hardly  painful;  but  little  blood 
is  lost,  and  the  wound  heals  readily. 
The  diagnosis  of  posterior  hyper- 
trophies is  not  difficult  when  a  good 
view  of  the  posterior  nares  can  be 
obtained  with  the  rhinoscope.  The 
peculiar  ashy  color  of  the  white 
growth,  its  rugous  surface  and  its 
situation  are  so  characteristic,  that  a 
mistake  can  hardly  be  made.  Polypi, 
however,  often  resemble  them,  but 
their  smooth  surface  and  the  history 
of  the  case  are  generally  sufficient 
to  indicate  their  nature.  The  red 
growths  are  by  no  means  as  common 
as  the  white.  Their  violet  hue  is 
also  characteristic,  while  their  soft 
consistence  and  their  tendency  to 
bleed  when  touched,  serve  to  differ- 
entiate them  from  fibrous  polypi  or 
osteomata,  with  which  they  might  be 
confounded.  When  examination  of 
the  parts  cannot  be  conducted  satis- 
factorily with  the  mirror,  much  in- 
formation can  be  obtained  by  intro- 
ducing the  index  finger  behind  the 
soft  palate,  and  gently  advancing  it 
until  its  palmar  surface  comes  in 
contact  with  the  posterior  border  of 
Author's modifica-  the  septum.  The  posterior  nares  can 

lion  of  Jarvis"  snare.     ,1  -i  •  -<  -i  i        ,1  Longitudinal   sec- 

then    be    easily   made    out,    and    the          ,i0n. 
conformation  and  density  of  the  parts  ascertained. 


HYPERTROPHIC   RHINITIS.  107 

Repeated  observation  has  demonstrated,  conclusively  in 
my  opinion,  that  local  medicinal  treatment  does  not  influ- 
ence posterior  hypertrophies,  and  that  in  all  cases,  some 
active  measure  must  be  resorted  to  which  will  affect  the 
growth  mechanically.  The  means  at  our  disposal  are  the 
same  as  for  anterior  hypertrophies : — acids,  galvano-cautery, 
and  the  galvano-caustic,  or  cold-wire  snare. 

Before  selecting  any  of  these,  however,  it  is  of  great  im- 
portance to  determine  whether  the  growth  is  principally 
apparent  through  extensive  distention  of  the  venous  sinuses 
— soft  hypertrophies — as  is  the  case  in  the  majority  of  the 
white  and  in  all  the  red  hypertrophies,  or  whether  the 
fibrous  tissue,  which  predominates  in  posterior  growths, 
forms  the  greater  portion  of  its  bulk — hard  hypertrophies — 
the  venous  sinuses,  in  that  case,  being  much  smaller  and 
fewer  in  number.  A  four  per  cent,  solution  of  hydro- 
chlorate  of  cocaine  can  be  used  for  the  purpose,  as  for  an- 
terior hypertrophies.  When  distended  sinuses  are  the  prin- 
cipal cause  of  the  turgescence,  immediate  contraction  will 
follow  and  the  tumor  will  almost  disappear,  whereas  if  true 
hypertrophy  of  all  the  layers  be  present,  the  influence  of 
the  drug  will  hardly  be  noticeable.  In  the  first  condition, 
acids  or  galvano-cautery  are  indicated,  because  the  snare, 
by  cutting  through  the  enlarged  and  engorged  sinuses,  would 
expose  the  patient  to  serious  hemorrhage,  while  in  the 
second,  the  snare  can  alone  be  effective,  the  acids  and  gal- 
vano-cautery being  comparatively  powerless  to  remove  the 
mass  of  exuberant  tissue,  which,  when  cut,  bleeds  but 
slightly,  if  at  all. 

The  position  of  the  growth  rendering  a  view  through  the 
anterior  nares  impossible,  the  direction  and  proper  location 
of  the  acid,  cautery  knife,  or  wire  loop  employed,  necessi- 
tates the  use  of  the  rhinoscope.  But  as  the  hand  which 


108 


DISEASES   OF   THE   ANTERIOK   NASAL   CAVITIES. 


should  hold  the  tongue-depressor  is  needed  for  the  oper- 
ating instrument,  the  former  must  either  be  held  by  the 
patient,  or  an  instrument  such  as  that  shown  in  Fig.  40,  a 
combined  tongue-depressor  and  rhinoscope  invented  by  Dr. 
Jarvis,  has  to  be  employed. 

For  the  application  of  acids,  the  little  instrument  shown 
below  will  be  found  very  convenient.  It  consists  of  a 
plated  tube  mounted  on  an  ebony  handle,  and  containing 
a  thin  rod,  which  is  flattened  near  the  end  and  curved, 
the  bent  portion  being  hardened  so  as  to  possess  enough 
spring  to  reassume  its  shape  after  being  straightened  out. 
A  slot  about  one  inch  in  length,  cut  through  the  upper  sur- 


Author's  chromic  acid  applicator. 

face  of  the  tube,  at  its  point  of  attachment  to  the  handle, 
exposes  the  near  end  of  the  rod,  which  is  here  furnished 
with  a  knob.  This  knob  is  perforated  horizontally  and  per- 
pendicularly, the  holes  thus  formed  accommodating  a  pin 
which  is  attached  to  a  flattened  spring,  which,  in  turn,  is 
bent  in  the  shape  of  an  arc,  and  is  screwed  to  the  handle. 
The  pin  fitting  loosely  in  either  of  the  holes,  the  spring  and 
rod  can  be  easily  disconnected,  and  the  latter's  curved  tip 
can  thus  be  pointed  in  any  direction,  after  which  the  pin 
can  be  inserted  in  the  hole  nearest  its  point.  When  pressed 
upon,  the  spring  drives  the  rod  before  it,  causing  its  end  to 
protrude  beyond  that  of  the  instrument,  and  draws  it  in 
again  when  the  pressure  is  released. 


HYPERTROPHIC   RHINITIS.  109 

Of  the  three  acids  mentioned,  chromic  acid  is  by  far  the 
most  satisfactory  for  posterior  applications.  Nitric  acid  is 
not  sufficiently  safe,  while  glacial  acetic  acid  requires  too 
many  applications. 

"When  an  application  is  to  be  made,  the  instrument  is 
adjusted  so  that  the  curved  tip  will  take  the  proper  direc- 
tion on  emerging,  and  the  end  of  the  rod  is  protruded.  The 
tip  is  heated  slightly  to  the  fire  of  a  match,  and  dipped 
among  the  crystals  of  the  acid,  then  allowed  to  re-enter  the 
tube.  Enough  of  chromic  acid  will  have  adhered  to  the  rod 
for  the  application.  The  tube  being  passed  through  the  nasal 
cavity  as  far  as  the  hypertrophy,  the  rhinoscope,  held  with 
the  left  hand,  is  placed  in  position,  and  the  parts  are  illumi- 
nated. The  location  of  the  tube  being  ascertained,  its  point 
is  placed  against  the  side  of  the  growth,  and  the  spring  is 
pressed  upon.  This  forces  the  acid-covered  point  to  emerge, 
the  bend  causing  it  to  apply  itself  against  the  growth.  By 
now  drawing  the  instrument  out  a  short  distance,  the  appli- 
cation can  be  made  more  effective,  the  point  thus  parting 
with  all  its  acid  on  the  hypertrophied  membrane  as  it  rubs 
against  it.  The  pressure  on  the  spring  being  then  released, 
the  point  disappears  in  the  tube,  and  the  instrument  can  be 
withdrawn.  A  solution  of  bicarbonate  of  soda,  used  pos- 
teriorly with  the  atomizer,  is  always  indicated  after  this 
operation,  to  neutralize  any  excess  of  the  acid  that  might 
have  remained  on  the  membrane,  and  to  limit  absorption. 
Four  or  five  applications  of  this  kind  generally  cause  marked 
shrinkage  of  a  moderate-sized  growth. 

Galvano-cautery  can  also  be  used  in  the  same  manner  by 
introducing  the  cautery  knife  d  (Fig.  33)  instead  of  the  acid 
application.  The  loop  is  introduced  cold  and  applied  against 
the  side  of  the  growth.  Its  position  being  ascertained  with 
the  rhinoscope,  the  circuit  is  closed,  the  handle  being  at 


110  DISEASES    OF   THE   ANTERIOR   NASAL   CAVITIES. 

the  same  time  tilted  to  one  side  so  as  to  cause  the  platinum 
tip  to  press  against  the  hypertrophy  while  hot.  When  the 
tumor  is  large  I  use  an  electrode  constructed  on  the  prin- 
ciple of  the  chromic  acid  applicator  the  loop  protruding 
instead  of  the  acid  covered  knob. 

When  the  hypertrophy  is  of  the  hard  variety,  and  the  use 
of  the  snare  becomes  necessary,  preference  should  be  given 
to  the  galvanic  snare,  if  that  can  be  obtained.  The  oper- 
ation can  be  performed  much  more  rapidly,  and  the  danger 
of  secondary  hemorrhage  is  avoided.  The  rhinoscope  must 
of  course  be  employed  as  for  the  application  of  acids,  the 
snare  being  held  and  guided  with  the  right  hand.  In  some 
cases  it  is  necessary  to  retract  the  soft  palate,  in  order  to 
avoid  its  tendency  to  adapt  itself  against  the  pharynx,  and 
interfere  with  the  view  during  the  application  of  the  loop. 
An  easy  manner  of  accomplishing  this,  is  to  tie  a  piece  of 
white  tape,  a  foot  long,  to  the  broad  end  of  a  small-sized 
urethral  rubber  bougie,  and  to  pass  the  latter  through  the 
nasal  cavity  until  its  end  is  seen  protruding  below  the  soft 
palate.  Being  seized  with  a  pair  of  forceps,  it  is  drawn  out 
through  the  mouth,  until  the  tape,  which  has,  of  course,  fol- 
lowed the  catheter,  protrudes  about  as  much  out  of  the  mouth 
as  its  other  end  protrudes  through  the  nose.  The  two  ends 
are  tied  sufficiently  tight  to  leave  a  satisfactory  space  at  the 
isthmus,  and  the  catheter  is  detached.  It  should,  if  possible, 
be  applied  on  the  same  side  as  the  tumor,  but  when  this 
cannot  be  done,  and  the  other  nasal  cavity  is  alone  perme- 
able, the  tape  can  be  passed  across  the  posterior  surface  of 
uvula  and  caused  to  emerge  through  the  arch  on  the  side  of 
the  hypertrophy  when  drawn  out. 

An  estimate  of  the  size  of  the  growth  having  been  formed, 
the  wire  loop  should  be  made  sufficiently  large  to  slip  over 
it  with  ease.  In  the  majority  of  cases  the  growth  pro- 


HYPERTROPHIC   RHINITIS 


111 


trades  sufficiently  beyond  the  outline  of  the  turbinated  body 
to  be  easily  caught  in  the  loop,  but  at  times  it  does  not, 
and  the  wire  slips  over  its  surface  without  engaging  it. 
When  such  is  the  case,  the  loop  should  be  bent  on  the  tube 
at  an  angle  of  about  fifty  degrees,  before  introducing  it. 

Fig.  40. 


1.  Author's  galvano-cautery  snare  in  position. 

2.  Rhinoscopic  view. 

When  traction  is  produced,  the  loop  will  first  straighten 
itself,  then  lean  over  to  the  opposite  side,  and,  if  properly 
adjusted,  encircle  the  tumor.  If  the  galvano-cautery  snare 
is  employed,  pressure  is  exerted  on  the  finger-lever  as  shown 
in  Fig.  40,  without,  however,  closing  the  -circuit.  This  will 
cause  the  wire  to  tighten  itself  around  the  growth  until  a 


112  DISEASES   OF   THE   ANTERIOR   NASAL   CAVITIES. 

pedicle  is  formed.  Leaving  it  in  this  position  for  a  few 
moments,  the  rhinoscope  is  withdrawn,  and  the  left  hand 
is  used  to  turn  the  milled  nut  at  the  end  of  the  instrument. 
The  circuit  being  now  closed,  a  quarter  revolution  of  the 
nut  will  cause  the  glowing  wire  to  bury  itself  in  the  tissues, 
coagulating  the  blood  in  the  severed  vessels  and  preventing 
what  hemorrhage  might  occur.  As  soon  as  the  nut  stops 
turning,  the  circuit  is  broken,  and  after  waiting  a  couple  of 
minutes  the  same  process  is  repeated,  to  be  again  arrested 
and  renewed  until  complete  separation  of  the  growth  occurs. 
With  the  cold  snare,  the  procedure  is  the  same,  only  that 
much  more  time  should  be  employed,  to  accomplish  the 
operation  safely.  Although  the  chances  of  hemorrhage  are 
very  small  in  hard  hypertrophies,  one  moderately  large 
sinus  would  be  sufficient  to  cause  copious  bleeding,  this 
usually  occurring  some  time  after  the  operation,  when  the 
physician  is  not  on  hand  to  arrest  it.  When  the  loop  has 
engaged  the  mass  firmly,  which  can  be  ascertained  by  with- 
drawing the  instrument  until  its  progress  becomes  arrested 
by  the  tumor,  a  few  turns  of  the  milled  nut  will  secure  it. 
The  exact  position  of  the  wire  should  now  be  determined 
with  the  rhinoscope,  and  if  satisfactory,  the  nut  is  turned 
slowly  until  firm  resistance  is  felt.  After  a  few  minutes 
another  turn  is  given,  repeating  the  periods  of  rest  and  trac- 
tion, until  the  growth  has  been  completely  severed.  The 
mass  usually  comes  out  with  the  snare,  but  when  it  does 
not  the  latter  should  be  used  as  a  probe  to  push  it  into  the 
posterior  nasal  cavity,  and  cause  it  to  drop  through  the 
isthmus  into  the  mouth;  or,  the  patient  can  be  directed 
to  inhale  violently  through  the  cavity  operated  in,  the  nostril 
of  the  other  side  being  closed  with  the  finger.  An  insuffla- 
tion of  pure  tannin,  practiced  with  the  instrument  shown 
in  Fig.  25,  will  greatly  lessen  the  chances  of  secondary  hemor- 


HYPERTEOPHIC  RHINITIS. 


113 


rhage,  and  the  patient  should  be  ordered  a  small  quantity 
to  use  as  snuff,  should  bleeding  occur. 

When   after   the   foregoing    measures  have  been  resorted 
to,  the  obstruction  to  respiration  remains  pronounced  through 


Fig.  AJ. 


Woakes'  nasal  plough  in  position. 

involvement  of  either  of  the  turbinated  bones  in  the  hyper- 
trophic  process,  a  portion  of  the  bone  has  to  be  removed. 
Dr.  Woakes'  (of  London)  nasal  plough,  shown  in  Fig.  41,  is 
the  most  satisfactory  instrument.  It  consists  of  a  chisel- 
like  blade,  curved  upon  itself,  with  one  of  its  edge-corners 

8 


114  DISEASES   OF   THE   ANTERIOR   NASAL    CAVITIES. 

projecting  more  than  the  other,  the  sharp  point  formed  being 
blunted  so  as  to  avoid  cutting  the  membrane  when  passed 
up  the  nostril.  A  pair  of  forceps  with  narrow  but  strong 
blades,  so  shaped  as  to  not  interfere  with  vision  when  in 
position,  are  used  to  grasp  the  edge  of  the  bone,  after  which 
they  can  be  locked  by  approximating  the  spring-catches 
near  the  rings.  The  plough  is  then  placed  with  its  concave 
surface  against  the  blades,  the  latter  serving  as  guide  for  it, 
and  pushed  up  until  the  piece  held  in  the  grasp  of  the 
forceps  is  completely  cut  off.  Copious  hemorrhage  follows 
the  operation,  but  it  soon  stops  of  its  own  accord.  The 
after-effects  are  hardly  noticeable  arid  the  relief  is  immediate. 
A  local  application  of  the  four  per  cent,  solution  of  cocaine 
prior  to  any  of  the  operative  procedures  described,  facili- 
tates them  greatly.  The  membrane  is  not  only  anesthetized, 
but  the  contraction  it  undergoes  increases  markedly  the 
lumen  of  the  cavity,  rendering  the  introduction  of  instru- 
ments much  easier  and  less  annoying  to  the  patient.  By 
constringing  the  blood-vessels,  it  limits  to  its  simplest 
expression  the  local  blood-supply,  diminishing  greatly  the 
momentary  hemorrhage  following  cutting  operations,  if  not 
entirely  preventing  it. 

ATROPHIC   RHINITIS. 
(Synonyms: — Dry   Catarrh;    Atrophic  Catarrh.) 

Etiology. — Atrophy  of  the  mucous  membrane  of  the  nose 
occurs  as  an  occasional  result  of  hypertrophic  rhinitis.  It 
may  present  itself  early  or  late  in  the  course  of  the  affection, 
this  depending  on  the  nature  of  the  original  irritating  cause, 
and  upon  the  surroundings  of  the  patient.  An  abnormally 
dry  state  of  the  atmosphere,  such  as  that  furnished  by  the 
hot-air  heaters  in  such  .common  use  in  this  country,  and  the 


ATROPHIC   RHINITIS.  115 

continued  inhalation  of  tobacco  or  of  other  smokes,  causing 
rapid  evaporation  of  the  secretions,  encourages  its  develop- 
ment. Abnormal  patency  of  the  nasal  chambers,  by  facili- 
tating the  accumulation  of  irritating  and  desiccating  agents, 
or  by  lessening  the  power  of  the  exhaled  current  when  the 
nose  is  blown,  thus  allowing  the  accumulation  of  discharges, 
tends  to  produce  the  affection.  It  may  be  bilateral  or  uni- 
lateral, the  other  cavity  in  the  latter  case  not  having  as  yet 
merged  into  the  atrophic  process. 

Patholoyi/. — When  the  affection  occurs  as  a  result  of 
hypertrophic  rhinitis,  the  pressure  exerted  by  the  adven- 
titious cellular  tissue  upon  the  glands  and  blood-vessels, 
causes  interference  with,  or  destruction  of  the  former,  and 
gradual  absorption  of  the  latter.  As  the  destruction  of 
the  glandular  elements  progresses,  the  surface  of  the  mem- 
brane becomes  more  and  more  deprived  of  the  lubricating 
action  of  their  secretion,  and  is  thus  exposed  to  the  direct 
action  of  the  irritating  agents,  which  now  remain  in  contact 
with  it.  As  a  consequence,  superficial  desiccation  occurs, 
pressure  is  exerted  upon  the  layers  beneath,  and  this, 
coupled  with  the  diminished  nutrition  occurring  as  a  result 
of  the  decreased  blood-supply,  sooner  or  later  produces  ab- 
sorption of  the  greater  part  of  the  membrane,  including  the 
corpora  cavernosa,  and  frequently  the  turbinated  bones. 

Those  glands  which  are  principally  affected  by  the  external 
irritant  become  engorged,  and  their  apertures  are  the  seat 
of  minute  abscesses.  Owing  to  their  great  number  and  their 
close  proximity,  the  latter  form  suppurative  areas,  over 
which  the  purulent  discharges  accumulate  into  masses  more 
or  less  thick.  The  contact  of  these  masses  soon  destroys 
the  underlying  ciliated  epithelium,  the  cells  of  which  are 
shed  abundantly,  and  the  discharges  not  being  softened  by 
mucus,  or  propelled  by  the  to-and-fro  motion  of  the  cilia', 


11C  DISEASES   OF   THE   ANTERIOR   NASAL   CAVITIES. 

remain  over  the  seat  of  their  production,  to  become  dry 
crusts  by  the  evaporation  of  their  watery  constituents,  until 
they  are  of  sufficient  thickness  to  be  loosened  by  the  exhaled 
current  of  air  and  discharged. 

Symptoms. — The  symptoms  of  atrophic  rhinitis  may  be 
said  to  be  almost  negative,  the  nasal  respiration  being  per- 
fect. "When  the  affection  is  of  long  standing,  a  sensation  of 
dryness  or  parchedness  in  the  nostrils  or  pharyngeal  vault 
causes  great  annoyance,  and  the  sufferer  makes  strenuous 
efforts  to  relieve  this  by  blowing  his  nose,  frequently  de- 
presses his  upper  lip  to  stretch  the  membrane,  or  by  inserting 
a  finger  into  either  cavity,  endeavors  to  stimulate  the  parts 
and  relieve  a  sensation  of  intense  itching  principally  located 
over  the  septum.  Frontal  headache  is  frequently  induced, 
or,  if  present,  it  is  aggravated  by  exposure  to  cold  air  or  to 
noxious  fumes,  dust,  etc.,  the  membrane  having  become 
extremely  sensitive  to  external  irritation,  through  the 
paucity  of  mucus  to  protect  it.  This  lack  of  fluid  involving 
also  the  olfactory  membrane,  the  odoriferous  particles  are 
not  dissolved,  and  the  sense  of  smell  is  consequently  ob- 
tunded  or  lost. 

The  principal  symptom,  and  the  one  which  causes  the 
patient  to  apply  for  treatment,  is  the  impure  character  of 
the  breath.  This  cannot  be  said,  however,  to  be  positively 
fetid,  but  is  sufficiently  disagreeable  to  render  close  prox- 
imity unpleasant.  It  is  quite  characteristic  of  the  affection, 
and  once  smelt,  can  be  readily  recognized.  In  the  majority 
of  cases  the  patient  is  cognizant  of  his  infirmity,  and  is 
rendered  very  unhappy  by  it.  Thin,  scaly  crusts  of  a  green- 
ish-gray color,  sometimes  tinged  with  blood,  are  frequently 
discharged  anteriorly,  and  sometimes  posteriorly  through 
the  mouth.  As  the  disease  advances,  however,  these  crusts 
become  much  thicker,  and  are  discharged  in  the  shape  of 


ATROPHIC   RHINITIS.  117 

flakes,  which  present  at  times  a  perfect  cast  of  the  surface 
which  they  covered. 

Anterior  rhinoscopy  reveals  an  abnormal  spaciousness 
of  one  or  both  cavities,  varying  with  the  duration  of  the 
disease.  The  color  of  the  membrane  is  about  normal,  but 
as  the  latter  becomes  congested  upon  the  least  irritation,  it 
usually  appears  red,  through  the  efforts  of  the  patient  to 
clear  his  nose  preparatory  to  the  examination.  The  scabs 
described  may  be  seen  on  either  'or  both  sides  of  the  cavity 
examined,  and,  adhering  tenaciously  to  the  site  of  their 
formation,  are  removed  with  difficulty,  even  with  the 
probe.  When  the  disease  is  of  long  standing,  the  turbi- 
nated  bones  may  be  so  absorbed  as  to  hardly  appear.  The 
pharyngeal  vault  can  be  seen  from  the  front,  and  upon  being 
examined  posteriorly,  presents  the  same  appearances  as  the 
anterior  cavities,  except  that  the  membrane  is  frequently 
glazed  and  parched,  this  condition  extending  in  a  large  pro- 
portion of  the  cases  to  the  lower  pharynx.  Scabs  can  be 
seen  adhering  to  the  membrane  in  the  sinuosities  of  the 
fossae,  around  the  margin  of  the  posterior  nares,  and  upon 
the  superior  surface  of  the  soft  palate. 

Prognosis. — Atrophic  rhinitis  is  perhaps  the  most  unsatis- 
factory of  the  nasal  affections  to  treat  successfully.  The 
diminished  vitality  of  the  membrane,  its  deficient  blood- 
supply,  the  loss  of  the  epithelium,  and  the  absence  of  the 
lubricating  glands,  are  obstacles  which  are  overcome  with 
difficulty  and  which  require  time  and  patience  to  influence. 
Fortunately,  the  most  disagreeable  symptom  to  the  patient— 
the  tainted  breath — can  be  so  kept  in  abeyance  as  to  relieve 
him  of  mental  anxiety.  There  is  no  doubt,  however,  that 
under  appropriate  and  steady  treatment,  the  condition  can 
be  so  improved  as  to  not  be  a  source  of  annoyance.  The 
affection  is  rarely  troublesome  after  middle  age. 


118  DISEASES    OF   THE   ANTEHIOK   NASAL    CAVITIES. 

Treatment. — The  most  important  portion  of  the  treatment 
of  atrophie  rhinitis  is  to  keep  the  nasal  cavities  as  free  as 
possible  from  crusts.  To  accomplish  this,  the  douche  (Fig. 
15)  is  very  satisfactory,  especially  if  used  posteriorly  and 
when  the  crusts  are  not  too  adhesive.  In  the  latter  case, 
Hall's  syringe  (Fig.  1C),  with  either  Cohen's  post-nasal  tube 
or  that  shown  in  Fig.  30,  will  be  found  invaluable.  Its  con- 
tinuous stream,  the  force  and  rapidity  of  which  can  be  con- 
trolled at  will,  is  well  calculated  to  drench  the  parts 
thoroughly  and  to  force  the  scabs  from  their  berth. 

Much  benefit  can  be  procured  by  a  proper  selection  of 
the  ingredients  to  be  used  in  the  cleansing  solution.  These 
must  possess  solvent  and  slightly  stimulating  properties,  the 
former  to  facilitate  the  removal  of  the  crusts  by  softening 
their  edges  and  penetrating  underneath,  the  latter  to 
encourage  the  formation  of  new  blood-vessels  by  stimu- 
lating those  which  have  remained  in  a  healthy  state,  thereby 
increasing  nutrition  and  the  formation  of  regenerative 
elements,  and  enhancing  the  action  of  the  active  treatment. 
Borax  possesses  both  qualities,  in  addition  to  that  of  being 
an  excellent  disinfectant,  and  can  be  used  with  good  effect 
in  light  cases.  But  when  the  disease  is  more  advanced, 
more  stimulation  is  necessary  to  influence  the  dormant 
vessels,  and  a  more  powerful  antiseptic  is  required  to  correct 
the  impurity  of  the  breath.  The  following  formula  fulfills 
these  objects  very  satisfactorily: 

Rr?      !••    T>  •  \  Facilitates  the  removal  of  the  crusts  by  increasing 

.    Sodll   LoraCIS  ^      the  solvent  property  of  , he  liquid. 

ii   Clllor.  aa  Bj        /          Stimulates  the  blood-yessd.  and   the  glandular  ele- 

J         f      ments  to  action,  and  tends  to  relieve  their  engorgement. 

/          Powerful   disinfectant.      Stimulates    the    superficial 

n    Permang.     gr.  X.  vessels,    and    encourages    resolution    of    suppurative 

(.     areas. 

M.  Sig. — To  be  dissolved  in  one  pint  of  water  at  100°  F. 

This  should  be  used  by  the  patient  at  regular  intervals, 


ATKOPHIC   KHINITIS.  119 

three  times  daily,  if  the  formation  of  crusts  is  rapid.  If  the 
latter  are  few  in  number,  however,  twice  a  day  will  suffice. 
Used  faithfully,  this  solution  is  sometimes  sufficient  to 
restore  the  membrane  to  a  comparatively  healthy  state, 
that  is  to  say,  as  far  as  the  patient's  comfort  is  concerned; 
but  its  use  has  to  be  continued  for  a  long  time,  in  some 
cases  one,  and  in  others  two  or  three  years.  Occasionally 
the  ablutions  must  become  a  permanent  part  of  the  daily 
toilet,  to  avoid  impure  breath,  once  daily  being  sufficient, 
however,  to  keep  the  cavities  free  from  scabs.  Carbolic  acid 
might  sometimes  be  used  with  good  effect,  but  its  odor 
renders  it  objectionable  to  most  patients.  Phenol-sodique, 
one  tablespoonful  to  the  pint  of  water,  takes  its  place  advan- 
tageously, without  leaving  a  disagreeable  smell. 

Before  instituting  active  treatment,  the  patient  should  be 
allowed  to  use  the  cleansing  solution  a  few  days,  after  which 
the  crusts  will  be  detached  with  more  facility.  Directing 
him  not  to  use  the  wash  at  least  three  hours  before  his 
next  visit,  sufficient  discharge  will  mark  each  suppurative 
area  to  indicate  where  the  applications  are  to  be  made. 
The  nostrils  being  well  dilated  and  illuminated,  each  scab 
should  be  carefully  raised  (or  wiped  off  with  a  cotton  pledget 
if  too  soft  to  be  raised)  with  a  probe,  such  as  Bosworth's 
(Fig.  31).  Another  probe  of  the  same  kind,  previously 
covered  with  cotton  and  dipped  into  the  solution  used, 
or  the  galvaiio-caustic  knife,  is  then  introduced,  and  each 
spot  is  touched  separately  and  carefully.  In  my  practice, 
I  have  used  the  galvano-cautery  knife  d  (Fig.  33)  at  white 
heat,  as  recommended  by  Fraenkel,  applying  its  flat  surface 
to  each  suppurative  area.  In  order  to  do  this,  however,  the 
battery  must  be  sufficiently  powerful  to  heat  the  platinum 
knife  suddenly,  notwithstanding  the  local  moisture.  The 
knife  is  introduced  cold,  and  as  soon  as  it  is  properly  located 


120  DISEASES    OF   THE   ANTERIOR   NASAL    CAVITIES. 

the  circuit  is  closed.  The  result  is  immediate  cessation  of 
the  discharge  and  complete  alteration  of  the  morbid  process, 
while  no  cicatricial  formation  occurs.  Not  more  than  two 
.-jpots  should  be  cauterized  on  each  side  at  one  sitting. 

The  next  best  agent  to  galvano-cautery  is  a  fifty  per  cent, 
solution  of  glacial  acetic  acid.  This  remedy  seems  to  modify 
the  suppurative  process,  changing  the  character  of  the  dis- 
charges from  the  thick  consistence  described  to  that  of  a 
glairy  mucus.  In  some  cases,  where  the  suppuration  is 
great,  the  pure  acid  may  be  used,  taking  care  not  to  touch 
the  surrounding  surfaces.  It  does  not  act  here  as  an  escha- 
rotic  as  in  hypertrophic  rhinitis.  This  is  probably  due  to 
the  fact  that  in  the  latter  affection,  the  epithelial  covering, 
for  which  glacial  acetic  acid  has  great  affinity,  is  generally 
intact,  while  in  the  former,  especially  in  the  suppurative 
areas,  it  has  disappeared. 

Cotton-wool  tampons,  as  suggested  by  Gottstein,  are  often 
very  effective.  They  can  be  introduced  by  means  of  a  probe, 
a  pellet  as  large  as  the  first  phalanx  of  the  little  finger 
being  massed  in  the  cavity,  leaving  a  breathing  space 
between  it  and  the  floor  of  the  nose.  Its  presence  induces 
a  certain  amount  of  irritation,  which  causes  copious  flow 
of  mucus;  this  not  only  keeps  the  membrane  moist,  but 
prevents  desiccation  of  the  discharges.  Some  cases  become  so 
accustomed  to  their  presence  that  they  can  bear  them  the 
greater  part  of  the  day,  changing  them  now  and  then.  In 
the  majority  of  cases,  however,  one  hour  in  the  morning  and 
one  in  the  evening  will  suffice. 

The  essential  oils  of  tar,  cubebs  and  eucalyptus,  used  for 
five  minutes  three  times  a  day  with  the  auto-insufflator 
(Fig.  27),  are  frequently  productive  of  good  effect.  They 
stimulate  the  glandular  elements  and  thus  encourage  the 
flow  of  lubricating  fluids.  The  stimulating  action  of  a  weak 


PLATE  in 


PLATE   III. 

FIGURK  1. — Female,  ret.  23;  posterior  view  of  large  posterior  hypertrophy  of  left 
inferior  turbinated  body  ;  removed  with  snare.  Patient  referred  by  Dr.  B.  F.  McElroy. 

FIGURE  2. — Female,  set.  20;  hypertrophy  of  middle  and  inferior  turbinated  bodies, 
both  sides,  causing  bilateral  stenosis ;  removed  with  snare.  Case  referred  by  Dr.  M. 
O'Hara. 

FIGURE  •">. — Dr.  Lefforts'  (of  New  York)  case  of  complete  occlusion  of  both  nasal 
cavities  by  hypertrophies,  complicated  with  adenoid  vegetations  of  the  vault. 


FIGURE  4. — Lateral  section  of  pharynx  and  larynx  ;  g,  Section  of  mass  of  hyper- 
trophied  adenoid  tissue  of  the  naso-pharynx  seen  in  Fig.  6  (uvula  cut  off). 

FIGURE  5. — Anterior  section  of  above,  showing  relation  between  nasal  cavities  and 
the  larynx.  (The  vocal  bands  in  the  latter  are  in  the  cadaveric  position) — 

a,  Superior  turbinated  bone.  e,  Junction  of  hard  and  soft  palate  (the  latter 

b,  Middle  "  being  cut  off). 

c,  Inferior  "  "  g,  Anterior   portion  of  the   pharyngeal  vault 

d,  Orifice  of  Eustachian  tube.  or  posterior  nasal  cavity. 

p,  Posterior  aspect  of  septum. 

FIGURE  6. — Posterior  section  of  pharynx,  showing  mass  of  hypertrophied  tissue 
in  the  posterior  portion  of  the  pharyngeal  vault,  as  seen  in  a  patient  in  whom  con- 
genital absence  of  the  uvula  existed. 


FIGURE     7. — Posterior  view  of  left  cavity  in  atrophic  rhinitis. 

S.— Lateral 

"         9. — Anterior       "         "  "  "  " 

"       10. — Rhinoscopic  view  of  left  cavity.     "  " 

11.—  "       "         mirror  slightly  turned. 

12. — Microscopical  section  of  the  mucous  membrane  in  atrophic  rhinitis. 


[NOTE. — The  Nos.  4,  5  and  6  had  to  be  shortened  one  inch  from  below  the  Eustachian  prominences  so 
as  to  enable  them  to  be  represented.     The  other  proportions  are  accurate  ] 


PJat  e  III. 


W  HBuTLCft  AG'LlTH.  fHILA 


ATROPHIC   RHINITIS.  121 

solution  of  nitrate  of  silver  applied  three  times  daily  with 
a  cotton  pledget,  is  sometimes  of  great  benefit.  It  induces 
the  formation  of  new  elements  in  the  membrane  and  causes 
prompt  resolution  of  the  suppurative  areas.  A  preparation 
called  "Listerine",  a  combination  of  the  essential  oils  of 
eucalyptus,  gaultheria,  thyme,  etc.,  and  benzo-boracic  acid, 
is  principally  efficient  when  the  membrane  is  not  too  sensi- 
tive. Mixed  with  equal  parts  of  water,  it  serves  as  an  excel- 
lent disinfectant  and  gentle  stimulant. 

Irritating  medicines  in  the  form  of  powder  are  warmly 
advocated  by  some  specialists.  Not  having  found  them 
satisfactory  in  my  practice  in  this  class  of  cases,  I  cannot 
recommend  them.  A  momentary  relief  is  experienced,  but 
this  is  of  short  duration  and  is  usually  followed  by  increased 
drvness. 


CHAPTER   VII. 

DISEASES   OF   THE   ANTEBIOll   NASAL   CAVITIES. — (Continued.) 


SYPHILITIC   IlIIINITIS. 


(Synonyms: — Specific  Rhinitis;    Specific   Catarrh;    Syphilitic  Ozcena  ) 

Etiology. — As  indicated  by  its  name,  tins  affection  occurs 
as  an  inflammatory  process  induced  by  syphilitic  intoxication. 
It  may  be  primary  through  contamination  by  direct  contact 
of  the  mucous  membrane  of  the  nostrils  with  syphilitic 
matter.  It  frequently  presents  itself  as  a  symptom  of  the 
secondary  period,  occurring  usually  between  two  and  nine 
months  after  the  primary  infection,  although  occasionally 
it  follows  it  sufficiently  early  to  be  considered  by  some 
authors  as  forming  part  of  it.  As  a  manifestation  of  ter- 
tiary syphilis,  the  affection  rarely  presents  itself  until  sev- 
eral years  after  the  initial  stage,  twenty  and  thirty  years 
frequently  elapsing.  Syphilitic  rhinitis  also  occurs  as  a 
result  of  heredity. 

Patholoyy. — Lesions  occurring  on  the  surface  and  in  the 
layers  of  mucous  membrane  in  general,  are  all  of  an  in- 
flammatory character.  In  the  nose,  as  in  the  other  por- 
tions of  the  mucous  tract,  the  eruptions  are  analogous  to, 
and  often  coincide  with,  those  appearing  on  the  skin,  their 
appearance  being  modified  by  the  structure  of  the  mem- 
brane, its  functions,  and  the  presence  of  more  or  less  irri- 
tating secretions.  The  superficial  lesions  may  present 
themselves  as  a  mere  local  hypera3mia  of  short  duration, 
or  in  the  shape  of  papular  protuberances  which  rapidly  lose 
their  epithelium  and  present  the  appearance  of  erosions,  or  as 
(122) 


SYPHILITIC   RHINITIS.  123 

round  or  oval  erythematous  patches,  the  epithelium  of  which 
comes  off,  after  having  degenerated  into  muco-pus,  leaving 
the  membrane  proper  bare  and  reduced  to  a  secreting  sur- 
face of  an  ashy  color  and  of  a  granular  aspect.  Left  to 
themselves,  these  patches,  which  are  manifestations  of  the 
so-called  secondary  period,  and  the  most  frequently  met 
with  in  the  nose,  gradually  spread,  bulge  out,  or  become  cup- 
shaped,  and  secrete  quantities  of  yellow,  offensive  muco- 
pus,  which  adheres  closely  to  them.  They  are  almost  always 
surrounded  by  a  red  areola,  indicating  circuitous  congestion. 
When  the  lesions  are  deeper-seated  as  a  result  of  tertiary 
syphilis,  all  the  layers  of  the  membrane  become  infiltrated 
and  an  hypertrophic  process  involving  the  blood-vessels 
and  glanduke  begins,  followed  by  the  deposition,  in  the 
meshes  of  the  new  elements,  of  quantities  of  small  prolifer- 
ating round  cells,  which  are  thought  to  be  characteristic 
of  syphilis.  This  hypertrophic  process  being  unevenly  dis- 
tributed, nodules  are  formed,  which  soon  ulcerate  through  the 
pressure  exerted  upon  the  blood-vessels  by  the  adventitious 
elements  themselves.  This  ulceration  may  end  in  resolution, 
and  be  followed  by  cicatricial  contraction,  or  the  underlying 
perichondrium  or  periosteum  may  become  involved  in  the 
ulcerative  process,  and  necrosis  of  the  cartilage  or  bone 
follow.  The  septum,  the  turbinated  bones,  and  the  ethmoid 
are  more  predisposed  to  necrosis  than  other  portions  of  the 
skeleton.  While  the  process  may  start  in  the  mucous  mem- 
brane, as  stated,  the  diathetic  influence  may  be  exerted  on 
the  bones  or  cartilages  primarily. 

Symptoms. — When  the  affection  is  primary,  ?>.,  a  result 
of  direct  contamination,  the  local  process  follows  the  same 
course  as  in  other  parts,  the  initial  sore  and  the  inflamma- 
tion causing  swelling  of  the  nose,  pain,  difficult  nasal  respi- 
ration, and  fever. 


124  DISEASES   OF   THE   ANTEKIOK   NASAL   CAVITIES. 

As  a  symptom  of  the  secondary  form  of  the  systemic 
disease,  syphilitic  rhinitis  usually  begins  with  an  attack 
of  mild  coryza,  which  gradually  increases  in  intensity  and 
soon  assumes  the  stage  of  purulent  exudation.  Examined 
anteriorly,  the  membrane  appears  puffy  and  congested,  with 
here  and  there  a  mass  of  greenish-yellow  discharge,  which 
emits  a  peculiar  fetid  odor,  quite  characteristic  of  syphilis. 
Later  on,  this  discharge  becomes  sanguinolent,  and  close 
examination  anteriorly  and  posteriorly  reveals  patches,  which 
at  first  are  of  a  darker  hue  than  the  surrounding  membrane, 
but  soon  assume  an  ashy-gray  color.  These  patches  are 
covered  with  masses  of  the  yellow  secretion  alluded  to,  and 
are  generally  surrounded  by  abnormal  redness.  The  dis- 
charges being  frequently  drawn  down  along  the  wall  of  the 
pharynx,  the  latter  may  become  involved  in  the  inflam- 
matory process  and  undergo  ulceration.  The  larynx  is  also 
exposed  to  the  same  danger. 

In  the  tertiary  form  of  the  affection,  the  deep-seated  origin 
of  the  pathogenic  process  causes  the  ulceration  immediately 
to  assume  a  formidable  character.  After  a  local  swelling 
of  varying  magnitude,  generally  accompanied  by  local  pain 
and  swelling,  a  deep  ulcer  makes  its  appearance,  with  ragged 
edges,  and  surrounded  by  a  red,  angry-looking  areola.  The 
discharge  covering  the  ulceratioris  is  greenish-yellow,  often 
streaked  with  blood  and  studded  with  shreds  of  necrosed 
tissue.  Its  tendency  to  become  rapidly  desiccated  causes  it  to 
be  soon  turned  into  crusts,  which  adhere  tenaciously  to  the 
ulcer,  and  impart  to  the  breath  an  odor,  the  fetidity  of  which 
is  beyond  description.  The  ulceration  may  eventually  un- 
dergo resolution,  or  the  underlying  bone  or  cartilage  become 
affected  by  the  inflammatory  process.  The  cartilage  of  the 
septum  is  usually  the  first  to  disappear,  causing  depression 
of  the  tip  of  the  nose;  the  vomer  soon  follows,  and  the 


SYPHILITIC   RHINITIS.  125 

patient  becomes  permanently  disfigured  by  a  flattened  nose. 
The  turbinated  bones  gradually  slough  away,  or  become 
detached  whole  or  in  the  shape  of  spicuke.  In  two  cases  in 
the  author's  practice,  the  antra  of  Highmore  were  pene- 
trated, and  could  be  examined  with  the  assistance  of  a 
small  rhinoscope  introduced  through  the  anterior  nares. 
In  aggravated  cases  the  bony  and  cartilaginous  structures 
of  the  entire  cavity  may  disappear,  the  soft  parts  being 
sometimes  included,  so  that  the  anterior  nasal  cavities  are 
represented  by  an  irregular  hole  in  the  centre  of  the  face. 
The  floor  of  the  nose  is  often  perforated,  giving  rise  to  great 
interference  with  speech,  and  rendering  deglutition  difficult, 
especially  that  of  liquids,  which  are  frequently  forced  into 
the  nasal  cavity.  The  disease  may  extend  to  any  of  the 
osseous  structures,  slowly  destroying  them,  until  the  cranial 
cavity  is  penetrated.  As  soon  as  necrosis  of  the  cartilages 
or  the  bones  begins,  the  odor  of  the  breath  changes  in  char- 
acter, and  becomes  so  penetrating  that  prolonged  ventilation 
of  the  apartments  in  which  the  patient  may  have  remained 
only  a  few  moments  becomes  peremptory. 

Hereditary  syphilis  of  the  nose  generally  presents  itself 
at  the  time  of  birth  or  soon  after,  or  in  the  second  decade 
of  life.  In  girls  it  often  manifests  itself  at  the  approach  of 
puberty.  In  the  infant,  its  symptoms  are  those  of  the  coryza 
of  nurslings  at  first,  soon  aggravated  by  the  character  of 
the  discharges,  which,  becoming  muco-purulent,  cause  ex- 
coriation of  the  upper  lip.  The  trouble  shows  little  tendency 
to  subside,  and  if  left  to  itself,  generally  assumes  a  dangerous 
character.  The  bones  of  the  nose  are  in  danger  of  being 
necrosed,  causing  permanent  disfigurement,  while  extension 
of  the  necrosis  to  the  bony  surfaces  in  close  proximity  to 
the  brain  may  follow,  rendering  a  fatal  issue  most  likely  if 
penetration  occurs.  In  youths,  the  disease  progresses  as  if  it 
were  the  tertiary  manifestation  of  direct  contamination. 


126  DISEASES   OF   THE   ANTERIOR    NASAL    CAVITIES. 

Prognosis. — The  affection  being  the  result  of  a  systemic 
dyscrasia,  a  cure,  in  the  true  sense  of  the  word,  could  only 
be  expected  if  the  latter  were  curable.  This  being  out  of 
the  question,  we  can  but  subdue  the  local  manifestation. 
With  this  object  in  view,  the  prognosis  may  be  said  to  be 
very  favorable,  provided  the  patient  be  not  too  exhausted 
to  withstand  the  necessarily  active  treatment. 

As  a  result  of  the  ulcerative  process,  bands  of  cicatricial 
tissue  may  compromise  seriously  the  functions  of  the  parts, 
including  the  Eustachian  tubes,  the  pharyngeal  apertures  of 
which  may  be  completely  closed. 

Treat mot t. — The  patients  rarely,  if  ever,  present  them- 
selves at  the  onset  of  the  local  trouble,  ascribing  the  early 
symptoms  to  a  slight  cold,  etc.,  and  generally  do  so  when 
the  impediment  to  the  nasal  respiration,  the  fetid  breath, 
or  the  pain  have  persisted  for  some  time.  The  history  of 
the  case,  coupled  with  the  objective  symptoms,  generally 
renders  a  proper  diagnosis  easy;  at  times,  however,  the 
presence  of  syphilis  cannot  be  ascertained  from  the  patient, 
especially  when  it  is  the  result  of  heredity.  Dependence 
must  then  be  placed  on  the  character  of  the  ulceration.  In 
secondary  manifestations,  the  color  of  the  mucous  patches 
is  quite  characteristic ;  in  the  tertiary,  the  nature  of  the 
ulcer,  its  excavated  surface  with  everted  edges,  the  color  of 
the  discharge  and  its  odor,  furnish  sufficient  evidence  to 
render  the  differential  diagnosis  positive.  When  necrosed 
bone  is  present,  the  penetrating  odor  of  the  breath  furnishes 
unmistakable  evidence,  which  can  be  verified  by  the  use 
of  the  probe. 

Unlike  in  the  affections  previously  described,  systemic 
medication  is  of  primary  importance,  while  local  measures 
are  valuable  to  limit  the  ulceration,  and  frequent  cleansing 
contributes  to  the  patient's  comfort  and  prevents  inflamma- 


SYPHILITIC  KHINITIS.  Il27 

tory  contamination  of  the  surrounding  parts.  In  secondary 
syphilis  of  the  nose,  resolution  frequently  takes  place  with- 
out the  assistance  of  remedies,  the  site  of  a  patch  being 
marked  by  a  cicatrix  which  eventually  disappears.  At 
times,  however,  liberations  assume  the  form  of  vegetations, 
which  retard  greatly  the  recovery.  The  red  iodide  of  mer- 
cury, administered  in  doses  of  one-sixteenth  of  a  grain  three 
times  daily,  has  in  my  hands  produced  the  most  satisfactory 
results.  It  should  be  continued  until  the  first  evidences  of 
ptyalism  occur,  when  a  course  of  iodide  of  potassium  will 
be  of  service  to  eliminate  it  from  the  system.  Locally,  the 
nitrate  of  silver,  fused  on  the  end  of  a  heated  aluminium 
wire,  causes  rapid  obliteration  of  the  ulcerations  by  destroying 
the  ulcerative  surface  and  stimulating  the  absorbents.  As  a 
cleansing  solution,  that  described  page  118,  used  with  the 
douche  or  with  Hall's  syringe,  is  very  efficient  in  keeping 
the  cavities  clear,  and  as  a  disinfectant. 

In  the  tertiary  form  of  the  affection,  mercurial  prepara- 
tions are  not  nearly  so  effective  as  the  iodide  of  potassium, 
but  the  latter  must  be  given  in  full  doses.  Beginning  with 
ten  grains  three  times  a  day,  one  grain  is  added  to  each 
dose  until  two  scruples  are  administered  each  time.  lodism 
generally  supervenes  when  the  half  of  that  quantity  is  taken, 
but  I  have  not  found  it  disadvantageous  to  continue  the 
administration  of  the  iodide,  notwithstanding  the  eruption 
and  the  coryza.  On  the  contrary,  the  latter,  by  increasing 
the  natural  flow  of  mucus,  prevents  desiccation  of  the  dis- 
charges, and  renders  their  elimination  much  easier.  The 
continuation  of  the  treatment  is  guided  by  the  effect  pro- 
duced, and  as  soon  as  evidence  appears  that  the  remedy 
is  mastering  the  disease,  the  dose  should  be  decreased  as  it 
was  increased,  one  grain  each  time. 

The  constitutional   treatment  should  be  assisted  by  such 


128  DISEASES   OF   THE   ANTERIOR   NASAL   CAVITIES. 

local  measures  as  the  state  of  the  nasal  cavities  may  warrant. 
Cleanliness,  obtained  by  means  of  the  solution  recommended 
for  the  secondary  form  is  essential.  It  not  only  corrects  the 
fetor  of  the  breath,  but  assists  the  local  curative  process. 

Considerable  difficulty  is  occasionally  experienced  in  re- 
moving the  crusts,  and  the  physician  is  sometimes  obliged 
to  extricate  them  himself  by  means  of  slender  forceps,  after 
having  softened  the  masses  with  a  saturated  solution  of 
bicarbonate  of  sodium,  applied  with  the  atomizer.  This  is, 
of  course,  only  necessary  when  the  patient  is  first  seen,  as 
after  that,  sufficiently  frequent  cleansing  will  prevent  the 
accumulation  of  discharges  and  their  desiccation. 

The  application  of  the  solid  nitrate  of  silver  is  as  service- 
able in  this  form  of  syphilis  as  it  is  in  the  secondary.  Its 
stimulating  properties  are  here  of  the  greatest  value,  and, 
in  conjunction  with  the  internal  treatment,  soon  cause  reso- 
lution of  the  ulcer.  lodoform,  insufflated  three  times  a  day 
by  the  patient  himself,  is  also  very  valuable,  but  its  dis- 
agreeable odor  renders  it  objectionable  to  the  majority  of 
patients. 

When  necrosis  of  the  cartilages  or  bones  is  present,  the 
pungent  character  of  the  breath  is  prevented  with  difficulty, 
and  sometimes  can  hardly  be  modified.  Carbolic  acid  (gr. 
v-lj),  phenol-sodique  (3j-lj),  and  permanganate  of  potassium 
(gr.  v-lj),  used  with  Hall's  syringe,  have  been  the  most 
serviceable  in  my  hands  for  the  purpose.  More  effective 
than  all,  however,  and  the  essential  condition  for  a  suc- 
cessful local  treatment,  is  the  immediate  removal  of  the 
dead  portions  of  the  cartilage  or  bone.  The  cartilage  of 
the  septum  is  generally  the  first  to  become  affected,  and 
that  at  its  line  of  union  with  the  vomer.  A  fistulous  opening 
usually  covers  the  seat  of  necrosis,  and  serves  for  the  intro- 
duction of  the  probe.  When  the  characteristic  sensation  of 


SYPHILITIC   RHINITIS.  129 

roughness  is  felt,  the  opening  is  enlarged  sufficiently  to 
allow  the  introduction  of  the  instrument  shown  in  Fig.  42. 
The  sharp  edge  of  the  spoon  being  applied  to  the  rough 
surface,  this  is  gently  scraped,  taking  care  not  to  exert  too 
much  pressure,  lest  penetration  occur.  When  the  surface  is 
smooth,  the  edges  of  the  fistulous  surface  are  trimmed  with 
a  sharp  bistoury,  and  the  wound  being  left  to  itself,  heals 
without  further  trouble.  The  same  procedure  can  be  em- 
ployed for  superficial  necroses  situated  in  the  portions  of 
the  cavities  accessible  anteriorly.  When  a  loose  piece  of 
bone  can  be  detected,  the  fistulous  opening  should  be  suffi- 
ciently enlarged  to  allow  its  withdrawal. 

Fig.  42. 


Volkmann's   curette. 

In  many  cases  the  septum  is  perforated,  and  the  circum- 
ference of  the  opening  presents  a  rough  edge  of  carious 
cartilage  or  bone,  which  breaks  down  very  slowly  and  main- 
tains a  profuse  discharge.  The  septal  punch,  shown  in  the 
chapter  on  the  diseases  of  the  septum,  can  be  utilized,  the 
semi-lunar  blade  serving  to  cut  the  irregular  edges  away,  or 
the  sharp  spoon  can  be  used  to  scrape  them  down  until 
normal  cartilage  or  bone  is  felt.  When  the  turbinated 
bones,  the  vomer,  and  the  perpendicular  plate  of  the  ethmoid 
are  involved,  ordinary  dressing  forceps  can  be  employed 
to  extract  the  diseased  bone  or  break  the  necrosed  portion, 
which  usually  projects  into  the  cavity.  They  sometimes 

9 


130  DISEASES   OF   THE   ANTERIOR   NASAL   CAVITIES. 

become  detached  of  their  own  accord,  and  instances  have 
been  reported  in  which  large  portions  of  dead  bone  had 
fallen  into  the  larynx  and  caused  dangerous  symptoms. 

In  hereditary  syphilis  of  the  nose,  the  symptoms  follow 
the  same  course  as  in  the  tertiary  form,  and  are  treated  in 
the  same  manner.  When  syphilitic  rhinitis  occurs  in  the 
infant,  calomel  seems  to  exert  the  most  satisfactory  influ- 
ence, administered  in  doses  of  from  one-half  to  two  grains 
three  times  daily,  according  to  the  age,  with  one  to  three 
grains  of  bismuth  to  prevent  diarrhoea.  The  nose  should 
be  kept  as  clean  as  possible,  a  difficult  matter  in  young 
children.  Sneezing,  induced  by  tickling  the  nostril  with  a 
feather  or  any  other  harmless  object,  is  sometimes  very 
effective,  the  sudden  blast  causing  the  contents  of  the  nose 
to  emerge  on  the  upper  lip ;  or,  a  small  syringe  may  be 
used  to  absorb  the  discharge,  while  absorbent  cotton  or  a 
piece  of  blotting  paper  can  also  serve  for  the  same  purpose. 
A  spray  of  the  carbolic  acid  solution  (gr.  i-5j)  or  of  that  of 
the  permanganate  of  potassium  (gr.  iii-lj),  often  succeed,  in 
conjunction  with  the  internal  treatment,  in  arresting  the 
affection  in  a  very  short  time.  When  the  ulcerations  are  per- 
sistent, iodoform,  applied  with  the  auto-insufflator  (Fig.  27), 
by  the  mother  or  attendant,  can  be  added  with  advantage. 

SCROFULOUS   RHINITIS. 

(Synonyms  :  —  Fetid     Coryza :     Scrofulous     Ozoena  ;     Ozrena  ;     Fetid 
Catarrh ;     Strumous    Catarrh.) 

Etiology. — As  its  name  implies,  scrofulous  rhinitis  finds 
its  origin  in  a  constitutional  weakness,  a  depressed  state 
of  vitality  through  which  resistance  to  external  influence  is 
diminished.  This  state  of  debility  may  be  due  to  inherited 
scrofula,  or  occur  as  a  sequel  to  eruptive  affections  such 
as  measles,  scarlatina,  smallpox,  diphtheria,  etc. 


SCROFULOUS   RHINITIS.  131 

Pathology. — The  abnormal  susceptibility  of  scrofulous  sub- 
jects to  inflammation  and  the  tendency  to  relapse  peculiar 
to  all  scrofulous  affections,  readily  explain  the  onset  of 
rhinitis  and  its  continuation.  This  susceptibility,  although 
more  or  less  general,  being  frequently  most  marked  in  the 
mucous  membranes,  the  exposed  position  of  the  nasal  cavi- 
ties to  atmospheric  perturbations  and  to  external  irritants, 
furnishes  an  explanation  for  the  almost  universal  prevalence 
of  rhinitis  in  persons  of  a  scrofulous  diathesis.  In  scrofu- 
lous inflammation,  there  is  a  remarkable  tendency  to  per- 
manent infiltration  of  the  affected  tissues,  which  infiltration 
is  much  less  readily  absorbed  than  in  the  healthy  subject. 
There  being  little  or  no  tendency  to  the  development  of 
new  blood-vessels,  nutrition  of  the  adventitious  elements 
is  not  carried  on,  and  the  organization  of  new  connective 
tissue  does  not  take  place,  as  in  hypertrophic  rhinitis,  for 
instance.  The  infiltration  is  sometimes  so  great  that  the 
corpuscles,  which  are  much  larger  than  in  normal  exudation, 
fill  the  sub-epithelial  layer,  penetrating  sometimes  to  the 
sub-mucous  layer,  and  many  are  thrown  out  on  the  surface, 
after  having  undergone  a  granule-fatty  degeneration.  These, 
with  what  mucus  may  be  secreted,  form  a  thick,  adhesive 
secretion,  possessing  to  a  high  degree  fermentative  prop- 
erties, and  tending  to  form  scabs.  Its  irritating  nature 
compromises  the  ciliated  epithelium,  which,  as  in  the  pre- 
ceding affection,  is  abundantly  shed,  and  the  physiological 
properties  of  the  latter  not  being  performed,  the  discharges 
accumulate  in  the  sinuosities  of  the  fossa?,  to  form  there, 
fetid  masses  which  contaminate  the  exhaled  breath.  The 
mucous  membrane  of  the  accessory  cavities  takes  part  in 
the  pathological  process  when  the  affection  is  of  an  aggra- 
vated form. 

Symptoms. — The  most  prominent   symptom   of    scrofulous 


132  DISEASES   OF   THE   ANTERIOR   NASAL    CAVITIES. 

rhinitis  is  the  fetid  discharge.  This  may  be  slight  or  great 
in  quantity,  but  the  latter  is  most  frequently  the  case.  It 
is  voided  anteriorly  and  posteriorly  in  the  shape  of  scabs 
or  lumps,  which  are  of  a  greenish-brown  color,  sometimes 
tinged  with  blood,  and  frequently  preserving  the  conforma- 
tion of  the  surface  which  they  covered.  The  fetidity  of 
the  odor  they  emit  depends  upon  the  length  of  time  the 
mass  has  lain  in  the  sinuosities  of  the  cavity,  undergoing 
decomposition.  When  the  evaporation  of  its  watery  con- 
stituents has  reduced  its  density  so  that  it  will  preserve 
its  shape,  the  emanations  from  it  are  almost  intolerable. 
When  they  are  in  situ,  each  breath  becomes  saturated  with 
the  foul  odor;  the  inhalations  infect  the  patient,  the  ex- 
halations the  surroundings,  and  make  the  presence  of  the 
sufferer  almost  unendurable.  The  mental  suffering  of  a  sen- 
sitive person  afflicted  with  this  disease  is  generally  very 
great.  The  cognizance  of  his  infirmity  causes  him  to  shun 
the  society  of  his  friends,  and  the  constant  dread  of  ren- 
dering himself  obnoxious  leads  him  to  seek  a  life  of  soli- 
tude. This,  coupled  with  the  toxic  effect  of  the  impure 
breath  he  is  forced  to  inhale,  generally  impairs  his  health ; 
his  complexion  is  sallow,  his  bowels  irregular,  and  occa- 
sional febrile  manifestations  occur,  principally  towards  even- 
ing. In  some  cases,  the  exhalations  seem  to  be  perma- 
nently foul,  this  being  probably  due  to  a  constitutional 
idiosyncrasy  which  may  be  compared  to  that  manifested  in 
certain  individuals  who  suffer  from  offensive  perspiration 
of  the  feet  and  axilla3,  which  is  constantly  present,  notwith- 
standing the  most  scrupulous  cleanliness.  The  nasal  dis- 
charge may  not  be  profuse,  but  it  is  prone  to  desiccate 
rapidly,  and  to  adhere  tenaciously  to  the  surface  of  the 
membrane,  in  which  case  the  breath  is  particularly  offen- 
sive, sufficiently  so,  sometimes,  to  impregnate  the  air  of  a 


SCROFULOUS   RHINITIS.  133 

large  room.  The  patient  seldom  perceives  the  fetidity  of 
his  own  breath.  The  other  symptoms  correspond  somewhat 
with  those  occurring  in  atrophic  rhinitis.  The  sense  of 
smell  is  frequently  blunted,  this  condition  being  probably 
due  to  infiltration  of  the  sub-epithelial  layer  of  the  olfactory 
area.  That  of  taste  is  necessarily  often  compromised.  Fron- 
tal headache  is  sometimes  very  distressing,  indicating  in- 
volvement of  the  frontal  sinus.  When  the  antrum  takes 
part  in  the  inflammatory  process,  pains  over  the  malar 
bones  may  be  present,  complicated  with  supra-orbital  neu- 
ralgia. Implication  of  the  sphenoidal  sinus  occasionally 
gives  rise  to  a  dull  headache,  located  on  the  top  of  the  head. 
When  the  affection  involves  the  accessory  cavities,  especially 
the  last-named,  defective  memory  is  frequently  complained 
of.  The  Eustachian  tubes  are  sometimes  involved,  catarrhal 
deafness  occurring  in  a  small  proportion  of  the  cases. 

Anterior  inspection  of  the  nasal  cavities  will  generally 
reveal  a  condition  resembling  somewhat  that  of  atrophic 
rhinitis.  They  are  usually  capacious,  the  ill-nourished  mem- 
brane having  shrunken  under  the  pressure  of  the  desiccated 
discharges.  Their  color  varies  from  the  normal  to  that 
induced  by  marked  congestion.  At  times,  however,  the 
cavities  are  almost  normal,  the  lumps  of  muco-purulent  dis- 
charge alone  testifying  to  the  presence  of  the  affection. 
Posteriorly,  the  appearance,  as  to  color,  corresponds  with  that 
of  the  anterior  cavities.  The  fossse  of  Rosenmiiller  are 
sometimes  obliterated  through  the  excessive  infiltration,  and 
the  vault  is  studded  here  and  there  with  purulent  masses 
more  or  less  advanced  in  the  process  of  decomposition. 

Prognosis. — The  affection  being  more  systemic  than  local, 
the  complete  eradication  of  the  nasal  trouble  could  only  be 
expected  were  we  able  to  rid  the  system  of  the  scrofulous 
diathesis.  As  this  is  now  considered  beyond  our  means,  we 


134  DISEASES   OF  THE   ANTE1UOR   NASAL   CAVITIES. 

can  but  mitigate  the  intensity  of  the  local  trouble,  and  place 
our  patient  in  a  condition  of  comparative  comfort.  As  he 
becomes  older,  the  disease  moderates  in  severity,  disap- 
pearing entirely  in  the  majority  of  cases  when  adult  life 
has  been  attained. 

Treatment. — Much  benefit  can  be  produced  by  efficient 
local  cleansing,  strict  attention  to  hygienic  measures,  and 
by  the  internal  use  of  alteratives  and  tonics^  The  nasal 
douche  is,  in  my  opinion,  the  most  efficient  instrument, 
while  Hall's  syringe  (Fig.  16)  becomes  necessary  wrhen  the 
tendency  to  desiccation  is  great  and  the  crusts  are  difficult 
to  detach.  The  cleansing  solution  described  on  page  118  has 
been  more  satisfactory  in  my  hands  than  any  other,  its 
stimulating  properties  contributing  greatly  to  the  limitation 
of  the  discharges.  The  frequency  of  its  use  depends  upon 
the  amount  of  secretion,  three  times  daily  usually  sufficing 
to  keep  the  cavities  free. 

The  hygienic  measures  consist  in  the  maintenance  of 
bodily  cleanliness,  thus  encouraging  the  secretory  functions 
of  the  skin.  Frequent  bathing,  alternating  the  ordinary 
tepid  bath  with  one  of  salt  water,  made  by  dissolving  one 
pound  of  rock  salt  in  the  quantity  of  water  generally  em- 
ployed, stimulates  the  capillary  circulation  of  the  skin, 
especially  when  vigorous  friction  is  practiced  over  the 
whole  body,  after  drying  it  thoroughly.  A  well  regulated 
diet  is  also  of  importance,  coupled  with  due  attention  to 
proper  intestinal  action. 

The  internal  treatment  should  be  guided  by  the  condition 
of  the  patient  as  to  general  health.  If  he  is  not  too  weak 
to  bear  them,  alteratives  are  sometimes  productive  of  excel- 
lent results.  The  syrup  of  iodide  of  iron,  gradually  in- 
creased from  five  drops  to  thirty  drops,  three  times  daily 
after  meals,  has  in  my  hands  caused  recovery  of  the  senses  of 


SCEOFULOUS   RHINITIS.  135 

smell  and  taste  in  a  patient  in  whom  they  had  been  lost  ten 
months,  this  action  being  probably  due  to  absorption  of  the 
infiltration  in  the  layers  of  the  olfactory  region.  Its  admin- 
istration can  be  continued  for  weeks,  until  marked  iodism 
occurs,  when  the  dose  can  be  gradually  decreased,  to  be 
again  steadily  increased  when  the  minimum  dose  has  been 
reached.  Tonic  doses  of  bichloride  of  mercury  (gr.  s'o)  admin- 
istered three  times  a  day, ,  act  more  rapidly  in  some  cases. 
Both  of  these  agents  should  as  much  as  possible  be  em- 
ployed in  connection  with  a  generous  diet.  When  marked 
anaemia  is  present,  the  tone  of  the  system  should  be  im- 
proved by  the  administration  of  tonics  and  chalybeates. 
Quinine,  iron,  and  strychnia,  or  the  syrup  of  hypophosphites 
(preferably  Fellows'),  Fowler's  solution  of  arsenic  (m.  v.), 
used  alternately  three  weeks  each,  have  produced  excellent 
effects.  Oleo-resin  of  cubebs,  ten  drops  on  a  lump  of  sugar 
every  four  hours,  seemed  to  moderate  the  discharge. 

Local  treatment  is  not  as  effective  in  this  affection  as  in 
those  described  in  the  preceding  chapter.  This  may  be 
accounted  for  by  the  degenerated  state  of  the  membrane, 
the  absorbing  powers  of  which  are  decreased,  owing  to  the 
paucity  of  blood-vessels.  Calomel,  fifteen  grains  to  four 
drachms  of  sugar,  as  recommended  by  Trousseau,  is  effective 
in  some  cases.  The  glycerite  of  carbolized  iodo-tannin, 
described  011  page  76,  has  been  of  benefit  in  some  cases, 
limiting  the  discharges  permanently  in  several  of  them. 
The  galvano-cautery  knife,  applied  flatwise  here  and  there 
to  the  membrane,  reduced  the  secretion  markedly  in  the 
cases  in  which  it  was  tried. 


CHAPTER  VIII. 

DISEASES   OF   THE   ANTERIOR   NASAL   CAVITIES. — (Continued) 


TUMORS. 


THE  anterior  nasal  cavities  aye  occasionally  the  seat  of 
tumors,  which,  in  the  majority  of  cases,  arise  primarily 
within  them,  or  may  involve  them  secondarily  through  ex- 
tension from  the  accessory  cavities  or  other  neighboring 
regions.  They  may  be  benign  or  malignant,  the  former 
being  by  far  the  most  frequently  met  with.  Among  the 
benign  growths,  the  most  common  form  is  the  nasal  polypus, 
of  which  there  are  two  varieties,  the  myxoma,  or  soft  mucous 
polypus,  and  the  fibroma,  or  hard  fibrous  polypus.  The 
papilloma,  or  warty  tumor,  and  cysts,  are  also  benign  growths, 
while  the  ecchondroma,  or  cartilaginous  tumor,  and  the  osteoma 
and  exostosis,  or  osseous  growths,  can  also  be  classified  among 
the  non-malignant  neoplasms.  The  malignant  tumors,  which 
fortunately  invade  the  nasal  cavities  but  rarely,  are  the  sar- 
coma and  the  carcinoma. 

MYXOMATA,    OR   MUCOUS   POLYPI. 

Mucous  polypi  are  most  frequently  found  growing  on  the 
upper  or  lower  surface  of  the  middle  and  inferior  turbinated 
bodies,  and  sometimes  the  superior.  They  occasionally  spring 
from  the  accessory  cavities,  especially  the  frontal  sinus, 
penetrating  into  the  nose  through  the  communicating  canal  or 
aperture  which  connects  them;  but  they  very  rarely  grow  from 
the  septum.  They  are  at  first  sessile,  but  as  they  grow, 
their  increase  in  size,  which  is  usually  very  slow,  manifests 
itself  principally  at  the  extremity,  so  that  a  neck  is  formed 
136 


MYXOMATA,  OE  MUCOUS   POLYPI.  137 

close  to  their  point  of  attachment,  which  gives  the  growth 
the  shape  of  a  pear.  This  is  not  always  the  case,  however, 
a  small  proportion  of  polypi  having  a  broad  base.  As  they 
grow,  they  assume  the  shape  of  the  surrounding  spaces,  and 
penetrate  into  them. 

Etiology. — Mucous  polypi  are  generally  considered  to  be 
due  to  chronic  inflammation  of  the  Schneiderian  membrane. 
Intra-nasal  pressure,  owing  to  narrowness  of  the  cavities 
or  to  a  deviation  of  the  septum,  seems  to  favor  their  forma- 
tion They  are  seldom  seen  in  children,  and  are  somewhat 
more  frequent  in  males  than  females.  No  underlying  dys- 
crasia,  syphilitic  or  scrofulous,  seems  to  influence  their 
growth. 

Pathology. — Gelatinous  polypi  grow  by  a  localized  increase 
of  the  submucous  layer  with  its  epithelial  covering,  the 
glands  of  which  may  either  be  absorbed,  undergo  cystic  dila- 
tation or  hypertrophy,  or  remain  in  their  natural  state.  This 
epithelial  layer  forms  the  outside  covering  of  the  growth, 
which  is  otherwise  mainly  composed  of  a  gelatinous  sub- 
stance, very  rich  in  mucine,  containing  bundles  of  connec- 
tive tissue,  cells,  glandular  and  epithelial  elements,  and 
sparsely  supplied  with  blood-vessels,  excepting  at  the  point 
of  attachment,  which  is  very  vascular. 

Symptoms. — The  symptoms  occasioned  by  the  presence  of 
nasal  polypi  depend  upon  their  position  in  the  cavities 
and  upon  the  size  the  tumors  have  attained.  At  first,  no 
discomfort  is  experienced;  but  as  the  growth  increases  in 
size,  the  lumen  of  the  cavity  is  more  and  more  compromised, 
and  respiration  through  the  nose  is  rendered  proportionately 
difficult.  When  the  weather  is  damp,  the  hygroscopic 
nature  of  polypi  causes  them  to  increase  in  bulk,  and  the 
obstruction  is  proportionately  marked  until  fair  weather 
returns.  At  times,  the  position  of  a  large  polypus  causes 


138  DISEASES    OF   THE   ANTERIOR   NASAL   CAVITIES. 

it  to  act  like  a  valve  in  the  cavity,  so  that  expiration  may 
be  freer  than  inspiration,  or  vice  versa.  This,  however,  is 
only  a  passing  symptom,  which  disappears  as  soon  as  the 
polypus  becomes  sufficiently  large  to  occlude  the  cavity  per- 
manently. When  such  is  the  case,  however,  damp  weather, 
by  increasing  the  intra-nasal  pressure  through  its  dilating 
influence  on  the  growth,  frequently  occasions  frontal  head- 
ache, violent  attacks  of  sneezing,  and  such  reflex  symptoms 
as  cough,  asthma,  facial  neuralgia,  fugitive  pains  in  the 
neck  and  chest,  and  other  portions  of  the  thorax.  A  pro- 
fuse whitish  discharge  is  usually  present,  which  gives  the 
breath  a  peculiar  mousy  odor,  and  which,  through  its  irri- 
tating character,  frequently  excoriates  the  margins  of  the 
nostrils.  The  sense  of  smell  is  greatly  impaired  in  most 
cases,  and  abolished  when  complete  occlusion  takes  place, 
while  that  of  taste  is  implicated  in  proportion.  The  voice 
becomes  nasal,  according  to  the  degree  of  obstruction.  The 
conjunctiva  is  generally  congested,  and  laehrymation  is 
present  when  the  tear  duct  is  occluded  by  the  presence  of 
the  polypi,  or  by  the  local  inflammatory  process.  Hemor- 
rhage is  an  occasional  symptom.  When  polypi  attain  a 
very  large  size,  they  may  induce  lateral  expansion  of  the 
nose  and  partial  absorption  by  pressure,  of  the  mucous 
membrane,  and  even  of  the  turbinated  bones,  a  fact  con- 
firmed by  a  case  under  my  care.  Reflex  asthma  is  occasion- 
ally due  to  the  presence  of  nasal  polypi,  as  first  shown  by 
Yoltolini  in  1872,  through  the  pressure  upon,  or  irritation  of, 
the  posterior  ends  of  the  turbinated  bones.  Cough  may 
also  have  the  same  origin,  as  demonstrated  by  J.  N.  Mac- 
kenzie. 

Mucous  polypi  are  of  grayish-white,  pearly  color,  some- 
times tinged  with  pink,  semi-translucent,  and  somewhat 
resembling  an  oyster.  Occasionally  they  appear  decidedly 


MYXOMATA,   OE  MUCOUS   POLYPI.  139 

red,  owing  to  great  vascularity.  When  pressed  upon  with 
a  probe,  they  are  easily  indented,  but  they  soon  resume  their 
normal  shape. 

Prognosis. — Soft  polypi  present  no  danger  to  life,  but 
their  presence  causes  great  annoyance  to  the  patient  and 
compromises  more  or  less  the  senses  of  smell,  taste,  and 
hearing.  Deformity  of  the  features  through  the  mechanical 
expansion  which  they  occasion  is  of  very  rare  occurrence. 
They  occasionally  degenerate  into  sarcoma. 

The  danger  of  recurrence  after  their  evulsion  by  me- 
chanical means  is  very  great,  unless  the  point  of  origin  be 
within  reach  to  receive  thorough  prophylactic  treatment. 
The  fact,  however,  that  polypi  most  frequently  grow  in 
the  deep  recesses  of  the  meati,  increases  the  liability  to 
recurrence,  through  the  difficulties  presented  to  the  intro- 
duction of  instruments. 

Treatment. — Gelatinous  polypi  may  be  treated  by  medi- 
cinal or  surgical  means.  When  there  is  much  discharge 
and  momentary  obstruction  by  hygroscopic  swelling  of  the 
growths,  a  powder  composed  of  equal  parts  of  alum,  tannin, 
and  pulverized  extract  of  coca,  has  several  times  proven 
beneficial  in  restoring  whatever  degree  of  nasal  respiration 
was  usually  present,  and  when  continued  for  a  length  has 
seemed  to  reduce  the  polypi.  It  should  be  used  as  a  snuff, 
four  times  daily,  the  auto-insufflator  (Fig.  27)  being  con- 
venient for  the  purpose.  Daily  applications  of  the  tincture 
of  the  chloride  of  iron,  applied  by  means  of  Bosworth's 
probe  (Fig.  31),  are  highly  recommended  by  Beverly  Rob- 
inson, of  New  York.  The  growths  gradually  shrivel  up, 
and  are  blown  from  the  nose  after  a  couple  of  weeks  of 
treatment. 

The  method  recommended  by  Donaldson,  of  Baltimore,  is 
especially  satisfactory  when  used  for  small  polypi.  It  con- 


140  DISEASES    OF   THE   ANTERIOR   NASAL   CAVITIES. 

sists  in  the  application  of  chromic  acid  to  each  growth  by 
means  of  a  pointed  glass  rod,  the  extremity  of  which  is 
previously  dipped  into  a  solution  or  paste  of  chromic  *K»id 
(100  grs.-!j),  and  then  forced  into  the  polypus.  The  growths 
shrink  through  coagulation  of  the  albumen  forming  the 
principal  component  of  their -mucin,  and  sometimes  fall  of 
their  own  accord. 

I  have  found  a  fifty  per  cent,  solution  of  carbolic  acid,  a 
few  drops  of  which  are  forced  into  each  tumor  by  means 
of  an  hypodermic  syringe,  very  effective  in  cases  in  which 
the  growths  were  very  soft.  Coagulation  is  induced  and 
contraction  follows,  which  sometimes  culminates  in  spon- 
taneous detachment  from  the  base.  When  the  polypi  are 
numerous,  not  more  than  two  should  be  treated  at  one 
sitting,  lest  inflammation  be  induced.  When  the  growths 
do  not  become  detached  of  their  own  accord,  they  are  easily 
picked  off  with  forceps. 

Of  the  surgical  means  at  our  disposal,  evulsion  by  means 
of  forceps  is  probably  the  method  most  employed.  The 
instrument  shown  in  Fig.  43,  can  be  employed  for  the  pur- 
pose, its  bend  enabling  the  operator  to  guide  its  tip  in  the 
cavity  without  having  his  view  obstructed  by  the  handle. 
The  great  difficulty  frequently  met  with,  is  the  proper  deter- 
mination of  the  point  of  attachment  of  each  polypus,  so  as 
to  be  able  to  grasp  it  between  the  blades  of  the  instrument. 
The  four  per  cent,  solution  of  cocaine,  however,  is  of  great 
assistance  here,  and  when  applied  freely  to  the  surrounding 
membrane,  causes  contraction  of  its  layers,  generally  ex- 
posing the  base  of  the  tumor,  and  increasing  the  working 
space.  Besides,  it  limits  markedly  the  hemorrhage,  which 
is  almost  invariably  present  when  the  forceps  are  used. 
The  growth  being  seized  at  its  base,  is  then  twisted  on  its 
axis  and  torn  out.  If  cocaine  is  not  used,  a  severe  hemor- 


MYXOMATA,    OR   MUCOUS   POLYPI.  141 

rhage  usually  follows,  which  obscures  the  view  of  whatever 
other  growth  may  be  present.  The  usual  practice  is  to 
renew  the  operation,  notwithstanding  the  bleeding,  until  all 
the  polypi  have  been  extirpated,  seizing  what  soft,  non- 
resisting  surface  may  present  itself  in  the  grasp  of  the  for- 
ceps, and  to  tear  it  out.  In  this  manner,  the  mucous  mem- 
brane proper,  and  sometimes  pieces  of  bone,  are  pulled  out, 
while  great  pain  is  inflicted  upon  the  patient.  Although 
this  method  presents  the  advantage  of  rapidity,  it  is  cer- 
tainly a  brutal  and  bloody  one,  and  more  calculated  to 

Fig.  43- 


Polypus  forceps. 

inspire  the  patient  with  a  desire  to  keep  all  future  polypi 
which  may  recur,  than  to  apply  for  relief.  A  much  more 
satisfactory  method,  in  my  opinion,  is  evulsion  by  means  of 
the  snare,  followed  by  the  application  of  galvano-cautery  or  of 
some  caustic  acid  to  the  site  of  the  tumor.  Straight  snares, 
such  as  that  shown  in  Fig.  38,  are  inconvenient  for  this 
purpose;  the  hand  of  the  operator  obstructs  the  view,  and 
the  milled  nut  does  not  cause  sufficiently  rapid  traction  on 
the  wire.  The  instrument  shown  in  Fig.  44  does  not  possess 
these  disadvantages,  and  enables  the  operation  to  be  per- 
formed rapidly  and  without  pain. 

It  consists  of  a  pair  of   ring  handles,  shaped  and   united 


142  DISEASES   OF   THE   ANTERIOK   NASAL   CAVITIES. 

like  those  in  Tiemann's  tonsillotome,  the  straight  blade  being 
furnished  with  a  narrow  cylinder  and  needle-rod  such  as 
that  in  my  snare.  The  needle-rod  being  connected  with  the 
curved  blade,  it  follows  all  the  motions  of  the  latter,  when 
the  rings  are  approximated  or  separated.  The  end  of  the 
cylindrical  tube  is  furnished  with  a  flattened,  bulb-like 
enlargement,  the  edge  of  which  is  grooved.  "When  the  wire 
loop  is  connected  with  the  needle  in  the  manner  described 
page  105,  traction  on  the  latter,  by  approximating  the  rings, 
will  cause  the  wire  to  follow,  and  the  end  of  the  loop, 


Author's  polypus  snare. 


instead  of  entering  the  tube  and  form  a  sharp  bend,  will 
rest  in  the  grooved  edge  of  the  bulb,  preserving  its  rounded 
form  at  the  portion  of  the  loop  which  would  otherwise  be 
the  bending  point.  This  arrangement  not  only  prevents 
"kinking"  of  the  wire,  but  renders  it  able  to  assume  the 
loop  shape  by  merely  separating  the  rings.  The  loop  can 
thus  be  contracted  or  enlarged  at  will.  An  important 
feature  of  this  arrangement  is  that  the  instrument  can  be 
introduced  into  the  nasal  cavity  with  no  loop  to  interfere 
with  its  proper  location.  Once  in  situ,  the  rings  of  the 
handle  are  separated,  and  the  loop  is  enlarged  as  required, 
and  being  slipped  over  the  growth  until  its  point  of  attach- 


MYXOMATA,    OR   MUCOUS   POLYPI.  14o 

ment  is  reached,  the  tumor  can  either  be  torn  off  or  cut 
off,  this  being  easily  done  by  reason  of  the  powerful  lever- 
age the  mechanism  presents.  For  my  part,  I  prefer  the 
cutting  operation.  Hemorrhage  almost  always  follows  when 
a  polypus  is  torn  away,  whereas  such  is  not  the  case  when 
the  growth  is  severed  close  to  the  membrane.  That  thorough 
extirpation  can  only  take  place  when  the  "  roots"  are  pulled 
away  is  doubtful  in  the  extreme,  since  polypi  frequently 
break  off  some  distance  from  the  seat  of  implantation  at  the 
narrowest  portion  of  the  pedicle.  By  cutting  the  tumor  off 
close  to  the  membrane,  no  hemorrhage  follows  to  obscure 
the  view  for  the  evulsion  of  the  other  polypi,  and  what  por- 
tion of  the  tumor  is  left  behind  can  be  thoroughly  destroyed 
by  the  application  of  galvano-cautery,  chromic,  or  glacial 
acetic  acid.  For  the  two  latter,  a  probe  such  as  Harrison 
Allen's  (Fig.  20)  may  be  used.  When  a  pedicle  is  easy  of 
access,  chromic  acid  fused  at  the  end  of  the  probe  is  the 
most  effective  agent,  while  parts  difficult  to  reach  are  best 
treated  with  glacial  acetic  acid,  which  can  be  applied  over 
much  greater  surface.  In  this  case  a  probe  is  bent  so  that 
its  tip  will  penetrate  into  the  sinuosity  in  which  the  polypus 
grew ;  the  instrument  being  then  withdrawn  and  armed  with 
a  thin  pledget  of  cotton,  the  latter  is  dipped  in  the  acid, 
then  applied  thoroughly  to  the  site  of  the  tumor.  With  this 
treatment,  I  have  seldom  if  ever,  had  recurrence  on  the 
same  spot,  while  the  result  was  far  less  favorable  in  extir- 
pation by  forceps. 

The  galvano-caustic  snare  may  also  be  used,  and  is  pre- 
ferred to  any  method  by  some  specialists.  The  procedure  is 
the  same  as  for  the  ablation  of  posterior  hypertrophies  (see 
Fig.  40),  the  wire  loop  being  pushed  up  as  near  the  attach- 
ment as  possible.  The  soft  consistence  of  the  growth  renders 
a  much  more  rapid  section  possible.  When  the  wire  has 


144  DISEASES   OF   THE   ANTERIOR   NASAL   CAVITIES. 

been  tightened  around  it  by  depressing  the  finger-lever, 
the  mere  act  of  closing  the  circuit  is  often  sufficient  to 
detach  the  polypus  from  its  base.  If  this  does  not  occur, 
another  movement  of  the  finger-lever  will  cause  the  glowing 
wire  to  penetrate  the  pedicle.  An  advantage  of  this  pro- 
cedure is,  that  if  the  tumor  can  be  cut  off  flush  of  the 
membrane,  the  cauterization  produces  sufficient  effect  upon 
the  latter  to  destroy  all  vestiges  of  the  severed  tumor;  but 
the  limited  resiliency  of  platinum  renders  this  procedure 


Morell  Mackenzie's  nasal  bone-forceps. 

very  difficult,  the  least  resistance  causing  it  to  bend  down- 
ward and  remain  bent.  Steel  wire,  on  the  contrary,  responds 
to  the  motions  of  the  canula,  and  adapts  itself  closely  to  the 
surface  on  which  the  tumor  is  attached. 

In  repeated  recurrence  of  polypi,  some  authors  advise 
the  removal  of  a  portion  of  the  underlying  turbinated  bone. 
Having  never  performed  this  operation,  I  can  only  state 
that,  according  to  these  authors,  the  operation  is  not  fol- 
lowed by  evil  results.  Dr.  Morell  Mackenzie's  punch  forceps 
(Fig.  45),  seems  to  ine  to  be  the  most  convenient  instrument 


MYXOMATA,   OB  MUCOUS   POLYPI.  145 

for  the  purpose.  "  It  consists  of  deeply-grooved  blades  some- 
what flattened  from  side  to  side,  opening  vertically  and  con- 
stituting a  tube  when  closed.  Each  blade,  in  fact,  is  a  half 
tube,  and  has,  therefore,  an  inner  and  an  outer  edge.  The 
inner  edges  of  each  blade  (those  which,  when  the  instrument 
has  been  introduced,  are  nearest  the  septum),  are  slightly 
serrated  to  enable  the  operator  to  seize  the  turbinated  bone 
securely.  Within  the  tube  formed  by  the  closed  blades,  a 
third  blade,  beveled  at  its  anterior  extremity  to  a  sharp 
edge,  like  a  chisel,  can  be  projected  forward  when  the  in- 
strument is  in  position.  The  forceps  is  introduced  with  the 
chisel  drawn  back,  and  the  tissue  to  be  removed  having 
been  firmly  grasped  by  the  forceps,  the  cutting  point  is 
driven  home  with  the  author's  free  hand."  Dr.  Woakes'  nasal 
plough  (Fig.  41),  it  seems  to  me,  would  also  be  very  useful 
for  the  same  purpose. 

When  the  polypus  is  situated  very  far  back,  or  protrudes 
into  the  posterior  nasal  space,  the  instrument  shown  in  Fig. 
44,  can  be  utilized,  either  through  the  anterior  cavities,  or 
posteriorly  by  means  of  the  curved  tube,  which  can  be  con- 
nected with  the  handles,  instead  of  the  straight  one.  In 
either  operation,  the  tube  is  introduced  with  the  wire  loop 
drawn  in,  and  when  the  extremity  of  the  canula  is  in  the 
desired  position  (which  can  be  ascertained  with  the  rhino- 
scope,  or  if  the  tumor  is  too  large,  with  the  finger  passed 
behind  the  soft  palate),  the  loop  is  allowed  to  expand,  and 
passed  over  the  tumor,  using  digital  assistance  if  required. 
In  moderately  large  polypi,  the  blades  can  be  approximated 
rapidly  and  the  growth  severed  in  an  instant ;  but  when  it 
is  very  large,  the  threaded'  screw  and  milled-nut  arrange- 
ment, attached  between  the  two  levers,  had  better  be  used, 
to  gradually  snare  the  growth  off.  This  is  to  avoid  hemor- 
rhage, should  large  vessels  be  present  in  the  pedicle  of  the 
growth.  10 


146  DISEASES   OF   THE   ANTERIOR   NASAL   CAVITIES. 

Electrolysis  is  another  method  occasionally  employed  to 
destroy  mucous  polypi.  A  zinc  or  silver  needle,  connected 
with  the  positive  pole  of  a  moderately  powerful  galvanic 
battery,  is  introduced  into  the  tumor,  while  the  other  sponge 
electrode,  thoroughly  wetted,  is  applied  over  the  nose.  A 
tingling  sensation  is  experienced  during  the  operation,  which 
is  not  followed  by  the  least  annoying  symptom.  When  the 
polypi  are  small,  a  few  sittings  are  generally  sufficient  to 
cause  their  destruction,  but  when  large,  several  are  required. 
Each  sitting  should  occupy  about  fifteen  minutes,  and  be 
renewed  every  three  or  four  days. 

FIBROMATA,    OR  FIBROUS   POLYPI. 

This  variety  of  nasal  polypus  is  much  more  formidable 
than  that  just  described,  and  may  present  itself  at  any 
period  of  life.  It  rarely  occurs  primarily  in  the  anterior 
nasal  cavity,  generally  invading  it  from  the  posterior  nasal 
or  the  accessory  cavities.  The  roof  seems  to  be  its  favorite 
site  in  the  nose,  although  cases  have  been  reported  in  which 
fibrous  polypi  sprang  from  the  septum,  the  inferior  tur- 
binated  bones,  and  even  the  floor.  They  grow  much  more 
rapidly  than  mucous  polypi,  regardless  of  surrounding  parts. 

Pathology. — Fibrous  polypi  arise  from  the  periosteum,  and 
occasionally  from  the  bone  proper.  Their  external  envelope 
is  the  same  as  in  the  gelatinous  variety,  but  their  bulk  is 
mainly  composed  of  fibrous  tissue  with  numerous  cells  and 
nuclei,  freely  supplied  with  blood-vessels.  Both  varieties 
of  polypi  may  be  represented  in  the  one  growth,  i.e., 
fibro-myxoma. 

Symptoms. — Fibromata  at  first  present  the  same  symptoms 
as  small  gelatinous  polypi,  but  as  they  grow,  this  similarity 
gradually  decreases.  When  obstruction  to  nasal  respiration 
begins,  it  is  constant  and  gradually  increases,  while  no  influ- 


FIBROMATA,  OR  FIBROUS  POLYPI.  147 

ence  is  exerted  by  dampness,  as  in  gelatinous  polypi.  When 
the  entire  lumen  of  the  cavity  has  become  occluded  by  the 
tumor,  its  growth  still  continues,  to  the  detriment  of  bones, 
cartilages,  etc.,  that  may  be  in  the  way,  causing  absorption 
of  the  osseous  walls,  and  penetrating  into  what  fissures  may 
be  formed,  and  sometimes  into  the  accessory  cavities.  When 
this  stage  is  reached,  the  walls  of  the  nose  proper  are  fre- 
quently forced  apart,  and  the  face  assumes  the  appearance 
termed  "frog-face."  Ulcerations  over  the  surface  of  the 
growth  give  rise  to  a  purulent  discharge,  and  to  frequent 
attacks  of  epistaxis.  Fibrous  polypi  sometimes  attain  an 
enormous  size,  and  give  rise  to  frightful  deformity  of  the  face. 

The  appearance  of  a  fibrous  polypus  differs  greatly  from 
that  of  the  soft  variety.  The  color  is  much  like  that  of 
the  surrounding  membrane — perhaps  somewhat  darker-red, 
with  a  large  vessel  here  and  there.  There  is,  of  course,  no 
translucency,  and  when  pressed  upon  with  the  probe,  it  is 
firm  and  resistant.  It  is  most  frequently  sessile.  Its  base, 
which  can  rarely  be  seen,  is  generally  very  broad. 

Prognosis. — Left  to  itself,  a  fibroma  is  liable  to  degenerate 
into  sarcoma.  The  growth  gradually  progresses  until  the 
patient's  vital  forces  are  exhausted  by  repeated  hemorrhages, 
while  his  death  may  be  caused  by  gradual  septicaemia, 
through  the  constant  swallowing  of  purulent  discharges. 

Treatment. — Radical  extirpation  by  surgical  means  can 
alone  be  of  benefit.  When  the  growth  is  small,  the  cold 
wire  snare,  or  better  still,  the  galvano-caustic  snare,  may  be 
employed  to  sever  the  tumor  as  close  to  its  seat  of  implan- 
tation as  possible.  When  the  growth  is  pedunculated,  this 
is  easily  accomplished,  but  great  difficulty  is  encountered 
when  it  is  sessile.  Its  location  in  the  majority  of  cases  ren- 
ders the  application  of  transfixing  needles  impossible,  while 
less  gentle  means,  such  as  tearing  the  growth  off  by  pieces 


148  DISEASES    OF   THE   ANTERIOR   NASAL   CAVITIES. 

with  forceps,  is  likely  to  be  followed  by  dangerous  hemor- 
rhage. Again,  when  the  tumor  is  situated  in  the  upper 
part  of  the  cavity,  extirpation  may  be  followed  by  fatal  con- 
sequences, owing  to  the  close  proximity  of  the  brain  and  its 
membranes.  Electrolysis,  described  under  the  preceding 
heading,  has  produced  very  satisfactory  results  in  the  hands 
of  Dr.  Lincoln,  of  New  York,  who  reduced  some  large 
tumors  prior  to  their  extirpation.  This  method,  if  used  per- 
sistently in  small  sessile  growths,  may  suffice  to  induce  their 
obliteration. 

When  the  tumor  cannot  be  reached  through  the  nares,  an 
operation  to  render  free  access  to  the  roof  of  the  nose  pos- 
sible, becomes  necessary.  Among  the  methods  employed,  the 
following  are  the  least  formidable:  — 

Rouge's  operation  consists  in  dissecting  the  upper  lip  and 
the  nose  proper  from  their  points  of  attachment  on  the 
superior  maxillary  bones,  then  doubling  the  detached  por- 
tions upward  on  the  forehead.  The  anterior  nasal  cavities 
are  thus  fully  exposed,  and  the-  tumor  is  within  easy  reach. 
This  operation  possesses  the  advantage  of  producing  no  dis- 
figurement. 

Cassaignac's  operation  is  to  partially  detach  the  nose  from 
the  face  by  severing  its  bony  and  soft  connections  above  the 
bridge,  on  the  one  side,  and  below.  The  uncut  side  serves  as 
a  hinge,  and  the  nose  can  be  turned  over  on  the  cheek  like 
the  lid  of  a  box, 

Ollier's  operation  consists  in  detaching  the  nose  from 
the  face  by  incising  the  soft  tissues  and  the  bones  on  both 
sides  from  the  root  down  to  the  edge  of  each  ala,  after 
which  the  nose  can  be  turned  down,  its  tip  resting  against 
the  upper  lip.  (Full  descriptions  of  these  operations  and  a 
number  of  others  will  be  found  in  works  on  general  surgery.) 

The  anterior  nasal  cavities  being  fully  exposed  and  the 


PAPILLOMATA.  149 

location  of  the  growth  ascertained,  the  galvanic  snare,  with 
the  assistance  of  Jarvis'  transfixing  needles,  is  probably 
the  most  satisfactory  method  at  our  disposal.  Hemorrhage 
is  much  less  likely  to  occur  than  when  the  cold  wire,  the 
knife,  or  the  forceps  are  used.  The  manipulation  is  the 
same  as  that  described  for  anterior  hypertrophies.  The 
same  may  be  said  of  tumors  which  can  be  treated  through 
the  anterior  nares  without  preliminary  operation. 

Strangulation  of  the  tumor  by  means  of  a  ligature  is  an- 
other method,  which  can,  of  course,  only  be  applied  to 
pedunculated  growths.  The  plan  is  objectionable  through 
the  repulsive  odor  to  which  the  sloughing  mass  gives  rise, 
and  the  danger  of  septica3mia. 

PAPILLOMATA. 

Papillomata  are  wart-like  growths  occasionally  found  in 
the  nasal  cavities  of  young  subjects.  They  are  most  fre- 
quently attached  to  the  septum,  and  to  the  inferior  turbi- 
nated  body.  They  vary  in  size  from  that  of  a  lentil  to  that 
of  a  small  chestnut,  and  present  a  light  brownish  color, 
with  an  irregularly  corrugated  surface. 

Pathology. — Papillomata  are  mainly  composed  of  connec- 
tive tissue  arranged  in  papillary  processes  on  the  surface, 
into  which  capillary  vessels  are  freely  distributed. 

Symptoms. — In  children,  papillomata  cause  considerable 
irritation  in  the  nose,  a  catarrhal  condition  being  main- 
tained, and  the  discharge  causing  excoriation  of  the  upper 
lip  and  the  edge  of  the  nostril.  Cough  may  be  induced  by 
the  reflex  irritation  occasioned  by  their  presence.  Sneezing 
is  also  a  marked  symptom  when  the  growth  is  sufficiently 
large  to  touch  the  septum,  its  size  also  causing  obstruction 
to  nasal  respiration. 

Treatment. — When    the    growths    are    small,   a   couple    of 


150  DISEASES   OF   THE   ANTERIOR   NASAL    CAVITIES. 

applications  of  nitric  acid  are  usually  sufficient  to  destroy 
them.  This  may  be  applied  with  Allen's  probe  (Fig.  20) 
armed  with  a  small  pledget  of  cotton.  When  they  are 
larger,  the  polypus  snare,  or  the  ordinary  wire  ecraseur 
(Fig  38),  can  be  used,  after  which  the  point  of  implanta- 
tion can  be  touched  with  chromic  or  glacial  acetic  acid  to 
prevent  recurrence. 

CYSTS. 

Cystic  growths  are  occasionally  met  with  in  the  nasal 
cavities.  They  are  grayish,  more  or  less  rounded  and 
smooth,  and  are  generally  found  in  the  posterior  nares. 
Their  resemblance  to  mucous  polypi  is  very  great,  their 
differentiation  being  difficult. 

Cysts  originate  in  the  mucous  membrane,  and  contain  a 
clear,  colorless,  viscid  fluid,  which  escapes  when  the  invest- 
ing sac  is  accidently  ruptured. 

Treatment. — Evulsion  by  means  of  the  snare  is  doubtless 
the  best  and  the  simplest  procedure.  Removal  of  these 
growths  is  not  followed  by  recurrence. 

ECCHONDROMATA. 

Ecchondromata  or  cartilaginous  tumors  are  not  infre- 
quently met  with  in  the  anterior  nasal  cavities.  They  almost 
always  spring  from  the  septum,  the  exceptions  springing 
from  the  frontal  and  ethmoidal  cells  and  from  the  floor  of 
the  nose.  The  septal  tumors,  which  are  frequently  associated 
with  deviations  of  the  septum,  grow  very  slowly  until  they 
have  attained  a  certain  size,  when  their  growth  ceases.  The 
tumor,  which  is  really  but  a  local  overgrowth,  then  causes 
more  or  less  trouble,  according  to  its  dimension.  Situated 
in  other  portions  of  the  nasal  cavities,  ecchondromata  assume 
great  importance,  behaving  much  like  fibrous  polypi,  although 
their  progress  is  less  rapid.  Their  attachment  is  by  a  broad 


ECCHONDKOMA.  151 

base.  On  the  septum,  they  are  usually  cone-shaped,  while 
in  the  other  portions  of  the  nose,  their  form  is  spherical. 

Pathology. — Ecchondromata,  when  originating  from  car- 
tilage, grow  from  the  deeper  layers  of  the  perichondrium. 
Those  which  arise  from  bone  start  from  the  medulla  and 
tend  to  cause  absorption  of  the  underlying  osseous  tissue. 
The  latter  occasionally  assume  a  sarcomatous  character,  and 
grow  much  more  rapidly  than  the  former. 

Symptoms. — In  septal  ecchondromata,  nasal  obstruction, 
proportionate  with  the  size  of  the  growth,  may  be  the  first 
cause  of  complaint.  If  the  tumor  is  large  enough  to  touch 
the  other  side  of  the  cavity,  erosion  of  its  surface  takes  place, 
and  a  sanious,  irritating  discharge  may  be  present.  Pain, 
occasioned  by  pressure  against  the  opposite  surfaces,  may 
also  be  induced,  while  headache,  sneezing,  impaired  intona- 
tion of  the  voice,  anosmia,  etc.,  are  of  occasional  occurrence. 
These  symptoms  usually  continue  without  aggravation  in 
septal  ecchondromata,  but  when  the  tumor  is  located  in 
other  parts  of  the  cavity,  and  is  of  a  semi-malignant  or 
sarcomatous  type,  its  rapid  growth  causes  the  same  symp- 
toms as  fibrous  polypi,  displacement  of  neighboring  portions 
of  the  nasal  walls,  deformity  of  the  nose,  etc.  Such  tumors 
tend  to  recur  after  removal: 

To  the  eye,  septal  tumors  do  not  differ  greatly  in  color 
from  the  surrounding  membrane.  Their  broad  base  serves 
to  distinguish  them  from  polypi,  which  are  extremely  rare 
on  the  septum,  while  they  can  be  differentiated  from  osseous 
tumors  by  the  introduction  of  a  fine  needle,  which  the 
former  would  not  admit  of.  In  the  other  portions  of  the 
nasal  cavity,  their  hardness,  their  spherical  form,  and  their 
regularity  of  surface  are  characteristic. 

Treatment. — Septal  ecchondromata  being  in  the  great 
majority  of  cases  located  just  within  the  nostril,  they  can 


152  DISEASES   OF   THE   ANTERIOR   NASAL   CAVITIES. 

be  readily  removed.  They  may  be  shaved  off  with  a  sharp, 
probe-pointed  bistoury,  or  transfixed  with  a  needle  and 
detached  by  means  of  the  cold  wire  or  the  galvano-caustic 
snare.  The  same  methods  are  applicable  to  ecchondromata 
occurring  in  the  other  portions  of  the  cavity,  below  the 
olfactory  region. 

The  tendency  of  ecchondromata  originating  from  bone  to 
cause  absorption  of  the  osseous  tissue  underlying  them,  be- 
comes an  important  consideration  when  surgical  measures 
are  to  be  adopted,  especially  when  the  neoplasm  is  located 
in  the  upper  part  of  the  cavity  near  the  brain.  Operative 
procedures  are,  therefore,  hazardous  when  the  tumor  is  situ- 
ated in  those  regions,  especially  if  it  is  of  large  size.  Should 
an  operation  be  deemed  advisable,  however,  the  means 
recommended  for  fibrous  polypi  may  be  employed. 

OSTEOMA. 

This  name  is  applied  to  a  rather  rare  form  of  osseous 
tumor,  which,  growing  from  the  mucous  membrane,  inde- 
pendently of  the  bony  framework  of  the  nose,  is  generally 
met  with  in  young  subjects.  In  some  cases,  its  starting  point 
is  in  the  accessory  cavities. 

Patlioloyy. — Osteomata  are  the' result  of  the  ossification  of 
newly-formed  connective  tissue.  They  may  be  of  great  hard- 
ness, in  which  case  they  consist  of  densely  crowded  osseous 
lamellae,  or  comparatively  soft,  cancellous  bone  preponder- 
ating in  their  internal  construction. 

Symptoms. — Pain  usually  accompanies  the  presence  of 
these  tumors,  through  the  pressure  they  exert.  Headache  is 
frequently  present,  and  epistaxis  is  an  occasional  symptom. 
They  are  pedunculated  in  most  cases,  hard  to  the  touch,  and 
are  either  the  color  of  the  surrounding  mucous  membrane 
or  somewhat  darker,  their  surface  being  irregular  in  outline. 


EXOSTOSIS.  lOo 

Where  they  are  sufficiently  large  to  touch  the  opposite  sur- 
face, they  become  eroded  and  give  rise  to  a  muco-purulent 
discharge.  Their  hardness  is  characteristic.  A  needle, 
which  will  penetrate  any  other  kind  of  growth,  will  not 
penetrate  an  osteoma. 

Treatment. — When  the  growth  is  not  very  large,  it  can 
generally  be  broken  off  with  the  polypus  forceps.  If  its 
pedicle  is  too  thick  to  allow  this,  the  little  saw  shown  in 
Fig.  46  will  soon  separate  it  from  its  point  of  attachment. 
Occasionally,  the  portion  connecting  it  with  the  mucous  mem- 
brane is  so  soft  that  it  can  be  easily  cut  with  scissors.  When 
deep-seated  in  the  nasal  cavity,  the  snare  can  be  used  as 
for  posterior  hypertrophies. 

EXOSTOSES. 

Exostoses  are  bony  growths  frequently  met  with,  which 
usually  spring  from  the  septum.  When  located  anteriorly 
they  are  situated  at  the  junction  of  the  latter  with  the  floor 
of  the  nasal  cavity,  presenting  the  appearance  of  a  spur  or 
pointed  crest.  When  in  the  middle  or  posterior  portions  of 
the  septum,  they  generally  assume  the  shape  of  a  longi- 
tudinal shelf  with  a  broad  base.  Their  growth  is  very 
slow,  and  is  arrested,  in  the  majority  of  cases,  when  a 
certain  size  has  been  attained  Occasionally,  their  crest 
seems  to  bury  itself  in  the  opposite  surface,  generally  the 
upper  portion  of  the  inferior  turbinated  body,  thus  forming 
a  bridge  across  the  cavity. 

Patlwloyy. — Exostoses  spring  from  the  periosteum,  and 
are  almost  always  composed  of  lamella  of  ivory  hardness, 
arranged  concentrically.  Cancellous  tissue  is  generally  ab- 
sent in  anterior  exostoses,  but  is  frequently  present  at  the 
base  of  middle  and  posterior  growths. 

Symptoms. — In  the  majority  of  cases,  exostoses  give  rise  to 


154  DISEASES   OF   THE   ANTERIOR   NASAL   CAVITIES. 

110  inconvenience.  Occasionally,  their  growth  is  not  arrested 
before  the  other  side  of  the  cavity  is  reached,  and  a  series 
of  symptoms  occur  much  like  those  due  to  the  presence  of  a 
foreign  body.  The  membrane,  first  irritated,  then  com- 
pressed by  the  apex  of  the  growth,  undergoes  an  inflam- 
matory process  with  profuse  secretion,  which  nothing  short 
of  surgical  procedures  can  arrest.  Pain,  due  to  pressure,  is 
sometimes  quite  severe,  and  manifests  itself  in  the  course  of 
the  fifth  pair,  while  reflex  asthma,  due  to  pressure  upon  the 
posterior  portion  of  the  inferior  turbinated  body,  may  be 
induced,  as  was  the  case  in  one  of  my  patients.  The  ob- 
struction to  nasal  respiration  is  hardly  ever  sufficient  to 
be  noticed.  Deflection  of  the  nose  is  sometimes  caused  by 
the  lateral  pressure  occasioned  when  the  exostosis  is  suffi- 
ciently large  to  rest  against  the  opposite  side  of  the  nostril. 

Fig.  46. 


Author's  exostosis  saw. 


Upon  inspecting  the  nasal  cavity,  a  growth  situated  in  its 
anterior  portion  can  be  readily  seen.  Hardness,  a  broad  base, 
and  a  light  pink  color  are  characteristics,  while  its  im- 
movability upon  its  seat  of  implantation  serves  to  differen- 
tiate it  from  an  osteoma.  It  bleeds  readily  when  touched. 
Situated  deeper  in  the  nasal  channel,  its  physical  properties 
cannot  be  as  readily  ascertained,  but  the  probe  will  be  found 
of  advantage  to  discern  its  conformation. 

Treatment. — When  exostoses  give  rise  to  active  symptoms, 
the  only  effective  procedure  is  to  remove  them.  This  can  be 
accomplished  by  a  number  of  methods,  among  which  the 
simplest,  perhaps,  is  by  means  of  the  fine  saw  represented  in 
Fig.  46,  the  teeth  of  which  are  so  disposed  as  to  cut  rapidly 
and  evenly  through  the  bony  tissue. 


EXOSTOSIS.  155 

When  the  growth  is  large,  the  periosteum  and  the  mucous 
membrane  should  be  detached  from  the  base  of  the  tumor  by 
means  of  the  knife  shown  in  Fig.  47,  the  upper  curved  portion 
of  which  is  blunt  on  top  and  very  sharp  below.  An  elliptical 
incision  being  quickly  made  around  the  growth,  the  blunt 
edge  is  passed  between  the  periosteum  and  the  bone,  and  the 
former  is  raised.  The  saw  being  then  passed  into  the  cut,  its 
elasticity  will  allow  it  to  bend  when  used,  and  a  cup-shaped 
surface  will  remain,  over  which  the  periosteum  and  the  mem- 
brane will  readily  adjust  themselves.  Performed  in  this 
manner,  the  operation  will  be  followed  by  no  annoying  after- 
effects. When  the  exostosis  is  deep-seated  in  the  cavity,  the 
saw  alone  can  be  used,  and  the  growth  detached  as  close  as 

Fig.  47- 


Author's  periostea!  knife. 

possible  to  the  septum.  The  surgical  engine  is  occasionally 
more  satisfactory  for  the  removal  of  these  growths.  A  small 
drill  or  burr,  revolved  sufficiently  fast,  cuts  effectively  into 
the  osseous  tissue  without  affecting  the  soft  membrane.  A 
small  incision  being  made  in  the  latter,  the  burr  is  introduced 
through  it  and  the  redundant  portion  of  bone  drilled  off, 
under  the  membrane.  The  case  alluded  to  above  was  treated 
in  this  manner,  the  entire  thickness  of  the  posterior  portion 
of  the  vomer  being  reduced  from  an  abnormal  local  thickness 
of  one-third  inch  to  that  of  one-eighth  inch.  The  most  satis- 
factory instrument,  in  my  opinion,  is  that  of  Dr.  Bonwill  (Fig. 
48),  which  combines  speed  and  great  delicacy  of  motion. 

In  bridge-like    exostoses    extending   from    the   septum   to 
either  wall  of  the  cavity,  the  surgical  engine  is  by  far  the  most 


15G  DISEASES   OF   THE   ANTERIOR   NASAL   CAVITIES. 

efficient  instrument  for  their  removal.     A  burr  with  a  dia- 


Bonwill's  surgical  engine. 


meter  corresponding  with  that  of  the  cavity,  is  rested  upon 
the  surface  of  the  growth,  and  pressure  is  exerted  upon  it  as 


SARCOMA.  157 

it  revolves.    The  sharp  instrument  soon  cuts  its  way  through 
the  growth,  shaving  it  off  the  septum. 

These  operations  are  usually  accompanied  with  much 
hemorrhage,  and  must  therefore  be  done  rapidly.  The  pain 
induced  is  remarkably  slight,  no  general  anaesthetic  being 
required.  This  is  especially  true  if  a  four  per  cent,  solu- 
tion of  cocaine  is  used.  It  not  only  prevents  what  little 
pain  would  otherwise  be  caused,  but  also  limits  bleeding. 
The  parts  heal  kindly,  without  giving  rise  to  systemic 
disturbances. 

t  Fig.  49- 


Burrs  for  surgical  engine. 
SARCOMA. 

Sarcoma  may  occur  primarily  in  the  nasal  cavities.  In  a 
large  proportion  of  the  cases,  its  starting  point  is  the  septum 
or  the  outer  wall  of  the  cavity,  soon  extending  to  the 
neighboring  parts.  Mucous  arid  fibrous  polypi  and  ecchon- 
dromata,  as  already  stated,  occasionally  degenerate  into 
sarcomata. 

Pathology. — The  pathological  characters  of  sarcoma  in  the 
nasal  cavity  are  the  same  as  those  presented  when  the  neo- 
plasm is  situated  in  other  parts  of  the  economy.  It  originates 


158  DISEASES   OF   THE   ANTERIOR   NASAL   CAVITIES. 

from  connective  tissue,  which  preserves  its  embryonic  type. 
The  cells  which  form  the  bulk  of  the  growth  are  principally 
the  round,  fusiform,  or  myeloid,  all  of  which  may  be  present 
together,  although  one  form  usually  predominates  to  a 
marked  degree. 

Symptoms. — The  first  manifestation  of  the  affection  is 
obstruction  to  nasal  breathing.  A  fetid,  greenish  and  some- 
times bloody  discharge,  due  to  superficial  ulceration,  soon 
sets  in,  and  pain,  due  to  the  expansion  of  the  surrounding 
parts,  follows.  The  conformation  of  the  latter  being  altered, 
the  features  may  become  deformed  if  the  tumor  grows 
anteriorly,  or  great  headache,  deafness,  dysphagia,  etc.,  may 
occur  if  the  growth  is  in  the  posterior  portion  of  the  nasal 
tract.  If  located  near  the  roof,  destruction  of  the  bones 
forming  it  may  take  place,  causing  death  by  extension  to 
the  brain. 

Sarcomata  usually  present  a  red,  fleshy  appearance,  assum- 
ing at  times  a  violet  hue.  They  bleed  easily  when  touched, 
and  communicate  a  doughy  sensation  when  a  probe  is  applied 
to  them.  They  are  generally  single  and  sessile. 

Prognosis. — The  rapidity  with  which  sarcomata  usually 
grow  in  children  makes  an  early  end  in  them  quite  proba- 
ble. In  adults,  their  growth  is  much  slower  and  the  chances 
of  an  early  and  complete  evulsion  are  thereby  increased. 

Treatment. — Thorough  extirpation  of  the  growth  is  the  only 
recourse,  when  the  patient  is  seen  sufficiently  early  to  render 
this  possible.  Imperfectly  done,  this  procedure  will  be  fol- 
lowed by  recurrence,  with  marked  increase  of  malignancy 
and  rapidity  of  growth.  Much  comfort  may  be  given  the 
patient  by  means  of  detergent  and  anodyne  sprays.  Morphia, 
and  belladonna,  either  of  which  may  be  added  to  a  borax 
solution,  or  a  five  per  cent,  solution  of  cocaine,  are  the  most 
effective  agents. 


PLATE  iv. 


PLATE   IV. 


FIGURE  1. — Male,  set.  38;  hyper- 
trophy of  entire  mucous  membrane  of 
nasal  cavities ;  relieved  by  means  of 
bougies  and  galvano-cauteiy.  ('use  re- 
ferred by  Dr.  T.  0.  Morton. 

FIGURE  3. — Rhinoscopic  view  of  above 
(normal  size). 


FIGURE  5. — Female,  ret.  2(> ;  appear- 
ance of  nasal  cavity  after  loss  of  septum 
and  turbinated  bones,  and  enlargement 
of  the  orifice  of  the  antrum  through  syph- 
ilitic necrosis.  Mercurials  and  iodides  ; 
extraction  of  necrosed  bones  with  forceps. 
Pot.  permang.  washes. 

FIGURE  7. — Rhinoscopic  view  of  above 
with  mirror  facing  obliquely  from  left  to 
right  (normal  size). 


FIGURE  9. — Female,  tet.  19  ;  mucous 
polypi ;  removed  with  snare,  subsequent 
galvanic  cauterizations. 

FIGURE  11. — Anterior  view  of  above 
(normal  size). 


FIGURE  i:>. — Female,  act.  30 ;  large 
fibrous  polypus  of  laryngeal  vault ;  re- 
moved with  galvanic  snare.  Dr.  Louis 
Jurist's  case. 


FIGURE  2. — Male,  set.  30 ;  syphilitic 
perforation  and  exostosis  of  septum  ;  mer- 
curial treatment,  and  mitigated  stick 
locally.  Case  referred  by  Dr.  L.  Web- 
ster Fox. 

FIGURE  4. — Rhinoscopic  view  show- 
ing exostosis  of  septum  in  the  above 
(normal  size). 


FIGURE  6. — Female,  set.  17;  syphilitic 
perforation  of  hard  and  soft  palate  ;  mer- 
curials and  iodides :  mitigated  stick 
locally. 


FIGURE  8. — View  of  palate  through 
the  mouth  (in  state  of  active  inflamma- 
tion). 


FIGURE  10. — Female,  ffit.  45 ;  large 
mucous  polypi ;  removed  with  snare ; 
subsequent  galvanic  cauterizations. 

FIGURE  12. — Anterior  view  of  above 
(normal  size). 


FIGURE  14.— Male,  set.  28 ;  central 
curvature  and  exostosis  of  septum  ;  longi- 
tudinal incision  with  knife ;  oakum  plugs ; 
exostosis  removed  with  saw.  Case  re- 
ferred by  Dr.  William  S.  Little. 


[NOTE  — Represented  as  seen  by  gas-light.     By  day-light,  the  red  color  appears  much  paler.] 


ate   iv. 


C.  E.  Sajous,  P/nxit. 


W.H.BUTLER 


CARCINOMA.  159 

CARCINOMA. 

True  cancer  of  the  nasal  cavities  is  of  rare  occurrence.  In 
the  majority  of  cases  it  presents  itself  in  children,  and  is 
either  of  the  encephaloid  or  epitheliomatous  type.  Scirrhus 
occasionally  occurs  in  subjects  beyond  middle  age.  It 
frequently  invades  the  nasal  cavities  from  the  surrounding 
parts. 

Pathology. — As  is  the  case  with  sarcoma,  carcinoma  presents 
the  same  pathological  characters  in  the  nose  as  in  other  parts 
of  the  system.  They  vary,  of  course,  according  to  the  variety 
of  cancer  present. 

Symptoms. — A  soft,  inflamed  pimple  is  generally  the  form 
first  assumed  by  the  growth.  This  rapidly  increases  in  size 
and  finally  opens,  a  thin,  brownish  liquid  escaping.  Severe 
pain  and  epistaxis  are  almost  always  present.  A  deep,  ragged 
ulcer  forms  at  the  opening,  which  spreads  to  all  the  neighbor- 
ing parts,  the  thickness  of  the  growth  increasing  at  the  same 
time.  The  cervical  glands  become  enlarged,  and  constitutional 
infection,  followed  by  extreme  exhaustion,  soon  causes  death. 

Prognosis. — Recovery  is  as  hopeless  as  when  carcinoma 
occurs  in  any  other  part  of  the  body. 

Treatment. — Operations  merely  advance  the  fatal  issue, 
unless  undertaken  at  the  very  start.  Palliatives,  nutrients, 
and  cleanliness  constitute  the  indications,  to  which  may  be 
added  the  application  of  mild  astringents,  which  are  said  to 
retard  growth. 


CHAPTEK  IX. 

DISEASES   OF   THE   ANTERIOR   NASAL   CAVITIES. — (Continued.} 
DISEASES  OF   THE   SEPTUM. 

THE  septum  being  implicated  in  almost  all  the  affections  so 
far  described,  the  majority  of  the  diseases  to  which  it  is  liable 
have  already  been  alluded  to.  This  chapter  will  therefore  be 
devoted  to  the  consideration  of  abnormal  conditions  which 
may  affect  it  independently  of  the  surrounding  parts. 

DEVIATION   OF   THE   SEPTUM. 

The  term  "deviation  of  the  septum,"  as  here  understood, 
means  a  lateral  curvature  of  the  septum,  which  may  be  per- 
pendiciilar  or  horizontal,  localized  or  general,  or  a  dislocation 
of  its  framework  from  the  middle  line,  sufficiently  marked  to 
interfere  with  the  functions  of  the  anterior  nasal  cavities. 

Etiology. — Few,  if  any,  subjects  may  be  found  in  whom  the 
septum  nasi  presents  a  perfect  perpendicular  plane.  It  gen- 
erally bends  or  curves  toward  one  side  or  the  other,  enlarging 
one  nasal  chamber  at  the  expense  of  the  other.  This  irregular 
conformation  is  ascribed  to  many  causes :  Inordinate  growth 
of  the  septum  as  compared  to  that  of  the  bony  framework  of 
the  nasal  cavity;  traumatism,  such  as  blows,  falls,  etc.,  by 
which  it  is  either  broken  or  forcibly  bent  to  one  side ;  great 
height  of  the  palatine  vault,  through  which  the  floor  of  the 
nose  and  its  roof  are  in  closer  proximity  than  normal,  the 
septum  (the  growth  of  which  continues  notwithstanding) 
being  bent  to  one  side  by  the  resistance  of  its  unyielding 
points  of  attachment  (Jarvis).  The  pressure  exerted  upon 
the  nose  in  the  act  of  blowing  is  also  considered  as  a  cause 
(160) 


DEVIATION  OF   THE   SEPTUM.  161 

by  B6clard.  Deviation  of  the  septum  is  more  frequently 
observed  in  males  than  in  females,  the  greater  degree  of 
exposure  to  which  the  former  are  liable  being  probably 
accountable  for  the  difference.  Bryson  Delavan  advanced 
the  opinion  that  hypertrophy  of  the  middle  turbinated  bone 
can  act  as  a  cause  of  deviation,  basing  his  opinion  on  the  fact 
that  in  eighteen  crania  in  which  it  existed,  sixty  per  cent, 
presented  hypertrophy  of  the  turbinated  bone  facing  the 
concave  side  of  the  septum.  I  am  more  disposed  to  consider 
such  an  hypertrophy  as  an  effort  of  nature  to  restore  as  much 
as  possible  the  normal  distance  between  the  sides  of  the 
cavity,  to  enable  it  to  perform  its  physiological  functions. 

Pathology. — The  deviation  may  involve  the  entire  septum 
or  be  limited  to  its  cartilaginous  portion,  the  perpendicular 
plate  of  the  ethmoid,  or  the  vomer,  but  in  the  majority  of 
cases,  the  cartilage  alone  is  affected.  The  bend  may  be 
angular  or  rounded.  In  the  former  case,  a  wedge-shaped 
prominence,  which  may  be  oblique,  perpendicular,  or  hori- 
zontal in  its  longitudinal  axis,  is  formed,  a  more  or  less  deep 
sulcus  or  sharply  defined  depression  existing  on  the  opposite 
side  of  the  septum.  In  the  latter,  the  prominence  is  smooth 
and  globular,  presenting  a  much  greater  degree  of  obstruction 
to  the  cavity  and  showing  a  corresponding  depression  on  the 
other  side.  Angular  curvatures  generally  exhibit  hyper- 
trophic  changes  at  the  apex  of  the  prominence.  At  the 
junction  of  the  cartilage  Avith  the  perpendicular  plate  of 
the  ethmoid,  a  simulated  deflection  which,  according  to 
Harrison  Allen,  is  due  to  hyperostosis  of  the  sutural  line, 
is  frequently  found.  In  these  cases,  but  little,  if  any,  depres- 
sion exists  on  the  other  side  of  the  septum.  The  deviations 
are  sometimes  double,  the  convexity  of  one  bend  presenting 
in  front  on  the  one  side,  and  the  convexity  of  the  other 
bend  presenting  further  back  on  the  other  side,  thus  forming 

11 


162  DISEASES   OF  THE  ANTERIOR  NASAL   CAVITIES. 

a  double  deviation  resembling  in  shape  the  letter  S.  In  cases 
of  fracture,  the  cartilage  is  the  portion  of  the  septum  most 
frequently  broken.  Next  in  order  comes  the  perpendicular 
plate  of  the  ethmoid,  its  articulation  with  the  vomer  being 
the  usual  seat  of  fracture.  The  vomer  is  very  rarely  in- 
fluenced by  the  concussion,  its  anterior  edge  being  posterior 
to  the  bones  of  the  face,  and  the  cartilage  yielding  to  the 
force  of  the  blow. 

Symptoms. — When  the  septum  is  considerably  deviated, 
there  is  usually  some  deformity  of  the  nose;  the  tip  may 
be  turned  to  one  side  or  the  other,  or  the  organ  may  appeal- 
depressed  just  below  the  nasal  bones,  or  assume  a  variety 
of  other  shapes.  The  degree  of  obstruction  to  respiration 
is  of  course  in  proportion  to  the  degree  of  the  deflection, 
complete  occlusion  sometimes  taking  place.  At  times  the 
complete  obstruction  is  due  to  the  atmospheric  pressure 
which  causes  the  alse  during  inhalation  to  adapt  themselves 
against  the  lower  edge  of  the  septum  on  each  side.  A  naso- 
pharyngeal  catarrh  is  almost  always  present,  due  principally 
to  the  interference  with  the  flow  of  the  secretions  anteriorly, 
causing  them  to  accumulate  behind  the  prominence  and  flow 
backward  over  the  sides  of  the  soft  palate,  down  along  the 
pharynx,  and  then  be  swallowed  or  expectorated.  The  cavity 
opposite  to  that  of  the  prominence  is  sometimes  the  seat  of 
chronic  inflammation  also,  its  patency  rendering  its  proper 
cleansing  difficult.  In  most  cases,  however,  there  is  com- 
pensatory hypertrophy  of  the  portion  of  the  turbinated  body 
lying  opposite  the  concavity  of  the  septum,  and  the  functions 
are  carried  on  normally  on  that  side.  Anosmia  is  a  frequent 
symptom.  The  voice  occasionally  acquires  a  nasal  intona- 
tion, especially  marked  in  antero-posterior  sigmoid  deflection, 
when  both  cavities  are  partially  or  completely  closed.  When 
the  prominence  presses  against  the  opposite  turbinated  body, 


DEVIATION   OF   THE   SEPTUM.  163 

erosion  of  the  latter  may  take  place,  which  gives  rise  to 
frequent  attacks  of  epistaxis.  Atrophy  may  be  induced 
through  the  pressure  exerted.  Catarrhal  deafness  is  an 
occasional  result.  The  convex  portion  of  a  deviated  septum 
may  be  confounded  with  a  polypus;  but  its  hardness,  and 
its  color,  coupled  with  the  corresponding  depression  on  the 
other  side  c^f  the  septum,  will  soon  establish  the  correct 
diagnosis.  The  varieties  of  deviation  are  so  numerous  that 
the  judgment  of  the  physician  is  greatly  taxed  in  each  case 
when  the  choice  of  a  procedure  is  to  be  made. 

Treatment. — Among  the  remedial  measures  proposed,  that 
of  Michel  is  perhaps  the  simplest.  The  patient  is  directed  to 
press  with  the  finger  upon  the  convex  portion  of  the  devia- 
tion several  times  daily.  After  a  time,  a  slight  deflection  can 
be  reduced  and  the  septum  returned  to  its  normal  s-hape.  In 
the  great  majority  of  cases  which  apply  for  treatment,  how- 
ever, the  deviation  is  too  marked  to  be  influenced  by  anything 
but  surgical  means.  The  least  difficult  operation,  and  one 
which  has  always  given  me  great  satisfaction,  in  simple  car- 
tilaginous deflection,  is  an  incision  through  the  protuberance, 
following  its  long  axis.  A  smart  hemorrhage  occurs  as  soon 
as  the  incision  is  made,  but  it  soon  ceases.  The  end  of  the 
finger  being  introduced  into  the  nostril,  the  septum  is  forcibly 
pushed  beyond  the  centre  and  maintained  there  by  packing 
the  previously  obstructed  nostril  with  carbolized  oakum.  The 
cut  edges  of  the  cartilage  override  each  other,  and,  after  a 
couple  of  weeks,  are  firmly  united.  The  oakum  plugs  should 
be  changed  daily  and  both  cavities  sprayed  with  a  solution  of 
permanganate  of  potash  (gr.  j-5j). 

A  method  recommended  by  Dr.  Fletcher  Ingals,  of  Chicago, 
in  anterior  cartilaginous  deviations,  is  to  make  an  oblique 
incision  through  the  membrane  of  the  convex  portion  of  the 
prominence.  He  then  detaches  the  membrane  a  certain  dis- 


164  DISEASES   OF   THE   ANTERIOR   NASAL   CAVITIES. 

'tance  on  each  side  of  the  cut,  from  the  underlying  cartilage, 
exposing  the  latter.  A  triangular  piece  is  then  cut  out,  the 
base  of  the  triangle  being  at  the  floor  of  the  nose.  Care 
should  be  taken  to  detach  the  cut  piece  from  the  lining 
membrane  of  the  other  cavity,  without  tearing  or  cutting 
through  it.  The  first  incision  is  then  closed  by  stitches  and 
the  cartilage  is  pressed  into  line  and  supported  by  means 
of  tampons. 

Dr.  John  B.  Roberts,  of  Philadelphia,  makes  a  long  incision, 
oblique  or  horizontal,  according  to  requirements,  through  the 
septum  from  back  to  front  along  the  line  of  deviation  or 
projection.  This  is  done  with  a  knife  introduced  into  the 
occluded  nasal  chamber.  If  the  bony  septum  is  deviated,  it 
is  divided  by  a  chisel  in  the  same  way  and  direction.  He 
then  introduces  a  long  steel  pin  into  the  normal  nostril,  and 
passes  its  point,  with  about  two-thirds  of  its  length,  through 
the  septal  cartilage,  a  short  distance  above  and  in  front  of  the 
incision.  This  brings  the  point  of  the  pin  into  the  occluded 
nostril.  Pressing  the  end  of  the  nose  and  septum,  according 
to  the  character  of  the  case,  into  proper  position,  he  brings 
the  "head-end"  of  the  pin  close  to  the  anterior  part  of  the 
septum  or  columella,  thus  causing  the  "  point-end,"  or  portion 
in  the  occluded  chamber,  to  lie  across  the  incision  and  adapt 
itself  lengthwise  along  the  surface  of  the  septum  beyond  the 
incision.  The  pin  is  then  pushed  in  up  to  the  head,  and  its 
point  is  thus  deeply  imbedded  in  the  soft  tissues  of  the  septum 
and  upper  and  posterior  part  of  the  occluded  chamber.  It 
may  be  said  that  theoretically,  the  point  is  by  this  movement 
passed-  through  the  cartilage  of  the  septum,  so  that  it  re- 
enters  the  nasal  chamber  by  which  it  was  originally  intro- 
duced, namely,  the  normal  one,  and  that  the  head  and  point 
are  on  the  same  side  with  the  severed  septum,  held  straight 
by  the  rigid  pin.  Practically,  however,  the  point  never  comes 


DEVIATION   OF  THE   SEPTUM.  165 

through  the  partition,  but  is  deeply  buried  somewhere  in  the 
neighborhood  of  the  superior  or  middle  meatus  of  the  ob- 
structed side  in  the  septal  or  perhaps  in  the  turbinated  wall 
of  that  side.  It  makes  little  difference  where  the  point  is 
fastened  so  that  it  is  firmly  fixed  and  holds  the  incised 
septum  straight.  Often,  two  pins  will  be  needed  to  correct 
this  deformity.  In  such  cases,  Dr.  Roberts  usually  inserts 
the  second  one,  not  from  the  mucous  surface  within  the 
nostril,  but  from  the  cutaneous  surface  of  the  dorsum  of 
the  nose  just  below  the  jiasal  bone,  having  previously,  if 
necessary,  forced  the  cartilage  loose  with  a  tenotome.  The 
operation  is  necessarily  a  bloody  one,  because  of  the  vascu- 
larity  of  the  parts  and  because  the  operation  will  be  useless 
unless  the  incision  or  incisions"  are  very  free,  so  as  to  take 
away  all  resiliency  of  the  cartilage.  If  the  deflection  of  the 
septum  is  a  general  rather  than  an  abrupt  one,  he  weakens 
the  septum,  after  the  primary  incision,  by  multiple  incisions 
with  the  stellate  punch,  which  should  make  large  cuts,  com- 
pletely through  the  cartilage.  The  pins  are  then  introduced 
as  before.  Any  spur  of  cartilage  or  bone  along  the  floor  still 
prominent  is  cut  away  with  the  knife  or  saw.  Dr.  Roberts  says 
that  it  is  sometimes  wise  to  thread  a  small  disk  of  rubber 
upon  the  pin  before  inserting  the  point,  as  carpet  tacks  are 
sometimes  given  a  leather  collar,  below  the  socket  when  the 
pin  has  been  thrust  entirely  in;  the  rubber  will  prevent  its 
head  from  ulcerating  through  the  tissues  and  thus  losing  its 
power  of  holding  the  parts  in  proper  position  until  union 
occurs.  The  pins  are  left  in  position  two  weeks.  This 
method  possesses  the  advantage  of  simplicity  and  effective- 
ness. The  patient  is  subject  to  but  little  inconvenience,  and 
the  cavities  can  resume  their  functions  at  once,  and  no  dis- 
figuring apparatus  is  apparent.  A  small  square  of  court 
plaster  will  cover  the  end  of  the  external  pin,  which  should 


1G6  DISEASES   OF   THE   ANTERIOR   NASAL   CAVITIES. 

have  a  flat  head.     The  other  does  not  show,  for  its  head  lies 
within  the  nostril. 

Another  method  of  dealing  with  deviation  of  the  septum 
is  to  forcibly  return  it  to  its  normal  position  by  means  of 
forceps,  as  suggested  by  Adams,  of  London,  who  used  an 
instrument  similar  in  shape  to  that  shown  in  Fig.  50,  and 
which  served  as  a  model  for  the  latter's  general  conformation. 
The  blades  being  introduced  separately  and  united,  like  ob- 
stetric forceps,  the  septum  is  grasped  firmly  and  moved  back 
to  the  median  line,  breaking  it  if  necessary.  After  being 
maintained  in  position  by  means  of  a  clasp  for  a  few  days, 
ivory  plugs  are  introduced  and  left  in  situ  until  the  cartilage 

has  become   firm.      Too  great    pressure    must    carefully  be 

i 

Fig.  5°- 


Author's  modification  of  Adams'  punch. 


avoided,  while  frequent  cleansing  should  be  practised.  After 
a  time  the  ivory  plugs  may  be  replaced  by  wadding  or  oakum 
ones. 

Blandin,  of  Paris,  overcame  the  unilateral  obstruction  to 
respiration  by  perforating  the  septum  by  means  of  a  punch, 
a  round  or  oval  hole  about  one-quarter  inch  in  diameter  being 
made.  A  disagreeable  feature  of  this  operation  is  that  the 
margin  of  the  opening  is  continually  covered  with  crusts, 
which  excoriate  the  underlying  membrane  and  keep  it  in  an 
irritated  and  sometimes  ulcerated  condition.  Steele,  of  St. 
Louis,  uses  a  punch  with  diverging  blades  (see  Fig.  51),  which 
serves  to  render  the  septum  flexible  prior  to  straightening 
with  forceps  such  as  Adams'.  The  subsequent  treatment  is 
the  same  as  in  the  latter  surgeon's  operation. 


DEVIATION   OF  THE  SEPTUM.  167 

The  modification  of  Adams'  forceps,  shown  in  Fig.  50, 
enables  the  operator  to  perform  the  different  operations  in 
which  such  an  instrument  is  required,  without  rendering 
necessary  the  possession  of  a  special  forceps  for  each  variety. 
The  punches  being  adjustable  in  a  perforation  near  the  ex- 
tremity of  one  of  the  blades,  any  shape  of  punch  may  be 
used  with  the  one  forceps.  Fig.  51  represents  a  set  contain- 
ing an  oval  Blandin  arid  a  Steele  punch,  an  elliptical  punch 
with  diverging  blades  to  cut  off  sharp  bends  of  cartilage  and 
reduce  its  elasticity  prior  to  straightening,  and  two  small 
blades — one  curved  and  one  straight — with  which  any  shape 
of  figure  or  cut  can  be  made  in  the  septum.  The  arrowhead- 


Fig.  Si. 


—   -H- 

Set  of  punches  and  blades. 

shaped  punch  serves  very  effectively  for  redundant  devia- 
tions. A  piece  of  that  shape  being  punched  out  with  the 
arrow  point  turned  towards  the  tip  of  the  nose,  the  punch- 
knife  is  detached  from  the  forceps,  and  the  latter  are  then 
used  to  bring  down  the  sharp  end  of  cartilage  into  the 
retiring  angle  of  the  cut,  where  it  is  kept  in  position  by 
means  of  carbolized  oakum  plugs.  When  the  deviation  is 
great,  the  straight  blade  can  be  used  to  lengthen  the  low.er 
line. 

The  after-treatment  of  these  cases  bears  great  influence 
upon  the  result.  Hard  plugs,  such  as  those  made  of  ivory, 
wood,  etc.,  are,  in  my  opinion,  not  recommendable.  The 
pressure  they  exert  interferes  with  the  nutrition  of  the  seat 
of  operation,  and  occasionally  gives  rise  to  sloughing.  Plugs 


168  DISEASES   OF   THE   ANTEIUOli   NASAL   CAVITIES. 

of  oakum  are  much  more  cleanly  and  exert  sufficient  pressure 
to  hold  the  parts  in  the  required  position.  They  should  be 
changed  at  least  once  daily. 

In  angular  deviations  complicated  with  hypertrophy  of  the 
tip  of  the  prominence,  a  bone  forceps,  such  as  that  shown  in 
Fig.  52,  is  sometimes  very  convenient.  The  edges  of  the 
blades  being  placed  behind  the  nodular  extremity  of  the 
bony  edge  formed,  a  firm  grasp  of  the  handles  will  cause 
the  growth  to  be  quickly  penetrated,  with  but  little  hemor- 
rhage. 

-Fig.  52. 


Nasal  bone  forceps. 

Cocaine  applied  before  any  of  these  operations  not  only 
prevents  pain  but  limits  the  bleeding  and  hastens  resolution 
of  the  cut  surfaces. 

II^lMATOMA   OF  THE   SEPTUM. 

As  a  result  of  direct  injury,  an  extravasation  of  blood  may 
take  place  between  the  framework  of  the  septum  and  its 
mucous  lining.  A  bulging  tumor  of  a  purplish-red  color  is 
formed,  giving  rise  to  more  or  less  obstruction  of  one  or  both 
cavities.  Sometimes  the  blood  is  absorbed  and  resolution 
takes  place,  but  at  other  times,  inflammation  occurs  and  an 
abscess  results.  The  history  of  the  case,  the  fluctuation  of 
the  tumor,  and  its  general  appearance,  make  the  diagnosis 
easy. 


ABSCESS   OF   THE   SEPTUM.  1G9 

A  small  extravasation  generally  disappears  of  its  own 
accord.  When  it  is  large  and  gives  rise  to  marked  obstruc- 
tion, some  of  the  blood  may  be  withdrawn  with  a  large 
hypodermic  syringe,  which  wrill  relieve  the  tension  and 
advance  resolution.  When  inflammation  presents  itself,  the 
growth  had  best  be  depleted  by  free  incisions. 

ABSCESS    OF   THE    SEPTUM. 

An  abscess  may  follow  an  extravasation  of  blood  or  present 
itself  after  a  traumatism,  as  a  result  of  the  local  inflamma- 
tion. It  may  be  of  short  duration  or  last  a  considerable  time, 
especially  when  it  is  due  to  necrosis  of  the  underlying  car- 
tilage. The  tumor,  which  is  generally  bilateral,  is  usually 
soft  and  yielding,  and  painful  when  touched  near  the  base. 
Perforation  of  the  cartilaginous  septum  occurs  in  the 
majority  of  cases,  especially  if  the  abscess  is  not  evac- 
uated early.  Free  incision  into  the  growth,  evacuating 
carefully  the  pus,  will  soon  bring  on  resolution. 

Abscess  of  the  septum  occasionally  occurs  as  a  result  of 
syphilis,  preceding  perforation  and  perhaps  destruction  of 
the  cartilaginous  portion.  In  these  eases,  deformity  of  the 
nose  may  occur,  a  subject  already  alluded  to  under  the 
heading  of  syphilitic  rhinitis. 

SUBMUCOUS   INFILTRATION    OF   THE   SEPTUM. 

This  condition  is  a  comparatively  frequent  accompaniment 
of  chronic  rhinitis,  as  shown  by  Cohen.  It  consists  of  an 
oedematous  tumefaction  situated  on  each  side  of  the  septum, 
generally  near  its  posterior  border,  contrasting  by  its  whitish 
color  with  the  surrounding  membrane. 

The  masses  may  be  torn  off  with  forceps  passed  behind  the 
soft  palate,  or  cauterized  by  means  of  galvano-cautery  or 
acids.  The  operation  should  be  conducted  with  the  aid  of 
the  rhinoscope. 


CHAPTER  X. 

DISEASES   OF   THE   ANTERIOR   NASAL   CAVITIES. — (Continued.) 

NEUROSES. 
PERIODICAL   HYPER^STHETIC   RHINITIS. 

(Synonyms: — Hay  Fever;  Hay  Asthma;  Rose  Cold;  Summer  Catarrh; 
Autumnal  Catarrh;  June  Cold;  Peach  Cold;  Rag-weed  Fever; 
Catarrhus  vEstivus;  Idiosyncratic  Coryza;  Coryza  Vasomotoria 
Periodica;  Pruritic  Rhinitis,  etc.) 

HYPER.ESTHETIC  RHINITIS  may  be  defined  to  be  an  affection 
characterized  by  periodical  attacks  of  acute  rhinitis,  compli- 
cated sometimes  with  asthma,  occurring  as  a  result  of  a 
special  susceptibility  on  the  part  of  certain  individuals  to 
become  influenced  by  certain  substances,  owing  to  a  deranged 
state  of  the  nerve-centres.  It  manifests  itself  only  provided 
the  mucous  membrane  primarily  affected  in  the  course  of  an 
attack  is  in  a  state  of  hypera3sthesia,  and  when  the  irritating 
substances  are  present  in  the  atmosphere. 

Etiolocjij. — Since  1819,  when  Bostock  first  described  the 
affection,  of  which  he  was  himself  a  sufferer,  numerous 
theories  have  been  advanced  to  explain  the  peculiar  period- 
icity of  the  affection  and  its  cause.  As  early  as  1839,  Elliot- 
son  pointed  to  pollen  as  the  probable  cause  of  the  affection, 
while  twenty  years  later,  Abbott  Smith,  Pirrie,  and  Moore, 
ascribed  its  active  cause  to  the  emanations  of  plants.  In 
1869,  Helmholtz  suggested  that  the  disease  was  due  to  the 
presence  of  vibrios  in  the  nasal  cavities,  which  remained 
dormant  in  the  winter  months,  and  became  active  through 
the  effect  of  the  summer  heat.  Twelve  years  ago,  Blackley 
(170) 


PERIODICAL   HYPER/ESTHETIC   RHINITIS.  171 

of  Manchester,  reiterated  Elliotson's  opinion,  that  the  affec- 
tion was  caused  by  the  pollen  of  flowers  and  grasses,  and 
demonstrated  by  a  series  of  experiments  the  power  of  these 
substances  to  bring  on  an  attack.  In  1876,  Beard,  of  New 
York,  published  a  monograph,  in  which  he  showed  that  a 
large  number  of  the  sufferers  were  of  a  nervous  tempera- 
ment, and  that  the  exciting  agents  were  very  numerous,  and 
not  limited  to  the  pollen  of  flowers  and  plants,  as  was 
formerly  thought.  In  1882,  Daly,  of  Pittsburgh,  published 
a  paper,  in  which  he  attributed  the  annually  recurring  attacks 
"  to  local  chronic  disease,  upon  which  the  exciting  cause  acts 
with  effect,"  adding  that  "  the  parts  should  be  put  in  order, 
and  thereby  enable  them  to  withstand  the  exciting  influence 
of  the  next  recurring  crop  of  bacteria."  In  1883,  Roe,  of 
Rochester,  N.  Y.,  advocated  the  same  theory,  and  stated  "  that 
hyperoesthesia  is  associated  with,  or  occasioned  by,  a  dis- 
eased condition,  either  latent  or  active,  of  the  naso-pharyn- 
geal  mucous  membrane,"  and  "  that  the  removal  of  the  dis- 
eased tissue  in  the  nasal  passages  removes  the  susceptibility 
of  the  individual  to  future  attacks  of  hay  fever."  Later  in 
the  same  year,  I  published  an  essay,  in  which  I  advanced 
"  that  hay  fever  was  due  to  an  idiosyncrasy  on  the  part  of 
certain  individuals  to  become  affected  by  certain  emanations," 
that  "  organic  alteration  of  the  surface  of  the  nasal  mucous 
membrane  altered  its  sensibility,  and  destroyed  what  morbid 
irritability  might  have  attended  the  nervous  filaments  dis- 
tributed over  it,"  and,  furthermore,  "that  hypertrophies  of 
the  nasal  membrane  increased  its  irritability,  and  the  inten- 
sity of  the  symptoms."  In  January,  1884,  Harrison  Allen,  of 
Philadelphia,  in  an  article  on  the  treatment  of  hay  fever, 
attributed  the  disease  to  permanent  or  temporary  obstruction 
of  one  or  both  chambers,  and  advanced  the  opinion  that  by 
overcoming  this  obstruction  by  the  usual  methods,  a  cure 


172  DISEASES   OF   THE   ANTERIOR   NASAL    CAVITIES. 

could  bo  effected.  In  June  of  the  same  year,  J.  N.  Macken- 
zie, of  Baltimore,  suggested  the  term  "Coryza  vaso-motoria 
periodica,"  on  the  ground  that  "the  disease  is  essentially  a 
coryza,  showing  in  most  cases  a  decided  tendency  to  periodic 
recurrence,  and  dependent  upon  some  functional  derangement 
of  the  nerve-centres  as  its  predisposing  cause,"  -and  stated 
that  "for  the  production  of  a  paroxysm,  a  certain  excita- 
bility of  the  nasal  cavernous  tissue  is  necessary  (brought  on 
by  a  multitude  of  external  irritating  causes),  plus  a  hyper- 
esthetic  state  of  (probably)  the  vaso-motor  centres." 

As  advocated  by  myself  in  my  paper  of  December,  1883, 
three  conditions  are  essential  factors  in  the  production  of 
an  access  of  hay  fever:  Firstly,  an  external  irritant;  secondly, 
a  predisposition  on  the  part  of  the  system  to  become  influenced  by 
this  irritant;  and  thirdly,  a  vulnerable  or  sensitive  area  through 
which  the  system  becomes  influenced  by  the  irritant. 

As  to  the  first  condition,  the  elaborate  and  persevering 
researches  of  Blackley  and  the  observations  of  Beard  on 
the  subject,  demonstrate  conclusively  to  my  mind  the  power 
of  certain  substances  to  produce  an  access  in  individuals 
susceptible  to  their  influence.  Blackley  caused,  by  applying 
to  the  mucous  membrane  of  certain  individuals,  less  than 
u^oth  of  a  grain  of  the  substance  to  which  they  were  sensi- 
tive, all  the  symptoms  which  presented  themselves  during 
the  course  of  an  ordinary  attack,  while  in  his  own  person 
the  simple  inhalation  of  pollen  produced  all  the  characteristic 
symptoms.  Cases  are  frequently  met  with,  in  which  the  mere 
approach  of  certain  substances  are  sufficient  to  bring  on  a 
paroxysm  even  out  of  the  usual  time,  while  the  removal  of 
the  subject  from  the  irritating  agent  in  the  midst  of  the 
yearly  period,  and  while  an  access  is  present,  will  cause  the 
latter  to  cease.  Again,  as  demonstrated  by  Dr.  Blackley,  the 
attacks  can  be  greatly  modified,  if  not  prevented,  by  placing 


PERIODICAL   HYPERJ2STHETIC   RHINITIS.  173 

in  the  nostrils  some  contrivance  which  will  purify  the  inhaled 
air  of  its  irritating  substances,  showing  plainly  the  power  of 
the  latter  to  induce  a  paroxysm. 

Another  evidence  that  pollen  is  a  factor  in  the  etiology  of 
the  affection,  is  the  regularity  with  which  the  majority  of 
plants  undergo  the  different  phases  of  their  growth,  each 
recurring  the  same  day  every  year,  and  in  some  the  same 
hour.  This  not  only  explains  the  periodicity  of  the  accesses, 
but  the  precision  with  which  most  sufferers  can  prophesy 
the  onset  of  their  attacks. 

The  mere  irritating  property  of  a  substance  is  evidently 
not  the  only  factor  in  the  production  of  the  attack.  This 
is  exemplified  by  the  fact  that  one  subject  may  be  affected 
by  a  certain  substance  which  will  in  another  be  absolutely 
harmless.  A  gentleman  under  my  care,  for  instance,  although 
a  great  sufferer  yearly  almost  since  birth,  can  take  rag- weed 
between  his  hands,  crush  it  and  inhale  its  emanations  without 
experiencing  the  least  ill-effect;  and  yet  this  plant  is  recog- 
nized as  one  of  the  greatest  enemies  of  hay  fever  sufferers. 
In  another  case,  the  pollen  of  roses  alone  produces  the  mani- 
festations and  all  others  are  absolutely  ineffective.  Subjects 
are  seldom  found,  however,  in  whom  a  single  agent  will  give 
rise  to  an  access,  the  majority  being  influenced  by  several 
substances,  with  one  in  particular  as  the  most  active.  Among 
the  substances  which  are  considered  as  causes  of  the  affec- 
tion, are  dust,  the  pollen  of  plants  in  general,  grasses  and 
cereals,  the  emanations  of  certain  flowers  and  perfumes,  fruit, 
animals,  sulphur,  smoke,  cinders,  etc.,  while  a  small  propor- 
tion of  the  sufferers  ascribe  the  origin  of  their  paroxysms  to 
summer  heat,  sunlight,  exposure  to  draughts  of  air,  etc. 

Dust,  as  observed  by  Beard,  is  the  most  common  irritant,  a 
fact  which  apparently  weakens  the  pollen  theory,  but  which 
in  reality  strengthens  it.  If  we  consider  that  pollen,  like  any 


174  DISEASES   OF   THE   ANTERIOR   NASAL   CAVITIES. 

^ 

other  substance,  is  subject  to  the  laws  of  gravitation,  and 
that  its  very  light  weight  is  a  provision  of  nature  to  insure 
its  far  as  well  as  near  dissemination,  and  its  final  fall  to  the 
ground;  and  that  immense  quantities  of  it  are  wafted 
through  the  atmosphere,  subject  to  the  mechanical  displace- 
ment of  its  currents, — we  can  understand  that  the  dust  of  the 
earth  is  but  a  part  of  what  is  generally  considered  as  dust, 
the  principal  of  its  other  constituents  being  an  agglomeration 
of  the  pollen  of  all  the  plants  in  the  surrounding  country, 
and  sometimes  of  those  of  distant  districts,  as  well  as  all 
ponderable  agents  capable  of  acting  as  irritants.  It  can  thus 
be  seen  that  dust  is  the  most  frequent  cause  of  hay  fever, 
because  it  is  the  common  carrier  of  all  the  obnoxious  agents. 
The  universal  distribution  of  dust  in  cities  as  well  as  in  the 
country,  furnishes  a  ready  explanation  for  the  prevalence  of 
the  disease  in  all  regions  excepting  in  those  which  contam- 
inated dust,  on  account  of  its  weight,  can  only  reach  in  very 
small  quantities  or  not  at  all,  such  as  high  altitudes,  the  open 
sea,  etc. 

The  entire  or  partial  freedom  which  the  so-called  "hay 
fever  resorts  "  enjoy  is  due  to  this  fact.  Very  few,  if  any,  of 
these  places,  however,  enjoy  absolute  immunity.  A  strong 
wind,  which,  having  passed  over  fields  and  become  impreg- 
nated with  their  pollen  or  with  the  dust  of  a  country  road, 
is  liable  to  bring  one,  a  few,  or  many  of  the  noxious  agents 
within  reach  of  the  susceptible  individual  and  cause  in  him 
the  manifestations  of  the  disease,  if  one  or  any  of  the  sub- 
stances to  which  he  is  sensitive  are  present.  It  thus  fre- 
quently happens  that  only  one  or  two  persons  among  many 
are  influenced.  That  some  resorts  insure  immunity  to  some 
people  and  not  to  others,  is  explained  by  the  fact  that  this 
immunity  depends  upon  the  presence  within  a  certain  radius, 
of  the  irritating  substance.  If  a  plant  to  which  a  subject  is 


PEKIODICAL   HYPEPwESTHFTIC   RHINITIS.  175 

sensitive  happens  to  grow  within  that  certain  radius,  the 
location  will  naturally  be  unfavorable  to  him. 

It  has  been  frequently  demonstrated  that  hay  fever  can  be 
induced  at  any  time  of  the  year,  and  in  regions  where  the 
disease  never  presents  itself  primarily,  as  in  high  altitudes  or 
on  the  high  seas,  by  the  accidental  presence  of  an  irritant, 
brought  there  as  a  part  of  the  dust  covering  clothes,  parcels, 
etc,  Wyman  and  his  son  were  thus  attacked,  while  spending 
the  hay  fever  period  at  a  resort  where  they  enjoyed  absolute 
immunity,  when  a  package  of  rag-weed  plant  was  opened 
there.  The  paroxysms  brought  on  by  handling  dusty  objects 
which  have  been  so  for  some  time,  or  those  occurring  at  sea 
several  days  after  leaving  port,  are  thus  accounted  for. 

The  extreme  degree  of  irritation  occasioned  in  most  suffer- 
ers by  riding  in  steam-cars  or  in  a  carriage  only  during  the 
hay  fever  period,  and  due  to  the  quantity  of  dust  shaken  up 
by  the  vehicle,  adds  further  evidence  in  favor  of  the  fact  that 
uncontaminated  dust  is  not  a  factor  in  the  production  of  an 
access,  since  dust  is  present  the  year  round  and  the  membrane 
is  not  irritated  at  all  times  of  the  year;  but  that  that  dust 
becomes  an  active  irritant  in  this  affection  only  when  con- 
taminated with  the  substances  to  which  the  subject  is  sus- 
ceptible. This  contamination  only  taking  place  at  a  certain 
period  each  year,  dust  is  only  an  irritant  during  this  period ; 
in  other  words,  it  only  acts  as  a  cause  of  the  affection  at 
certain  seasons,  because  it  is  only  during  those  seasons  that 
the  pollen  in  its  active  state  is  present  in  it. 

As  to  the  second  condition  essential  to  the  production  of  an 
access,  a  predisposition  on  the  part  of  the  system  to  become 
inordinately  influenced  by  certain  substances,  a  close  ex- 
amination into  the  family  history  of  the  patient,  and  into 
his  own  since  birth,  will  elicit  much  evidence  towards  prov- 
ing that  there  is  a  systemic  dyscrasia,  through  which  the 


176  DISEASES   OF   THE   ANTEKIOK   NASAL   CAVITIES. 

resisting  power  to  certain  diseases  is  diminished.  In  a  list 
of  forty  cases  now  before  me,  I  find  that  thirty-five  per  cent, 
have  near  relatives  who  present  a  clear  history  of  hay  fever 
or  rose  cold,  and  that  forty-two  per  cent,  have  asthmatic 
relatives.  It  is  thus  shown  that  in  a  majority  of  cases  (the 
percentage  of  family  histories  presenting  either  asthma  or 
hay  fever  being  fifty-five)  there  is  an  inherited  predisposition 
to  the  affection. 

Going  further  and  taking  a  glimpse  into  the  early  life  of 
these  cases,  I  find  that  forty  per  cent,  have  had  six  of  the 
diseases  incident  to  childhood,  that  sixty  per  cent,  have  had 
at  least  five,  eighty- two  per  cent,  at  least  four,  ninety  per  cent, 
at  least  three,  and  that  none  were  exempt,  while  one  only  had 
but  one  of  them.  These  diseases  were  whooping-cough, 
measles,  mumps,  chicken-pox,  scarlet  fever,  and  croup.  This 
singular  proclivity  to  so  many  of  these  affections  is  certainly 
not  a  mere  coincidence,  the  number  of  cases  being  too  large 
to  render  such  a  proposition  tenable.  It  seems  to  indicate  a 
predisposing  state  of  the  system  to  all  affections  in  which  a 
neurotic  element  plays  an  important  part,  evidenced  in  the 
exanthemata  by  the  eruption,  in  whooping-cough  by  the 
abnormal  irritability  of  the  pharynx,  larynx  and  trachea, 
in  the  mumps  by  the  marked  tendency  to  reflex  metastasis, 
and  in  croup  by  the  spasmodic  element  inducing  the  dysp- 
nceal  paroxysms.  That  an  inherent  liability  to  these  dis- 
eases must  be  present  is  further  demonstrated  by  a  com- 
parison with  the  histories  of  forty  persons  not  subject  to 
hay  fever,  in  whom  ninety-two  of  the  so-called  diseases  of 
childhood  had  occurred,  representing  an  average  of  two  and 
two-tenths  per  cent.,  while  in  hay  fever  sufferers,  one  hundred 
and  eighty-nine  children's  diseases  had  presented  themselves, 
an  average  of  four  and  seven-tenths  per  cent. 

Still  more  curious  in  this  connection,  is  the  fact  that  of  the 


PERIODICAL   HYPERJESTHETIC   RHINITIS.  177 

forty  cases  upon  which  these  remarks  are  based,  all  have  had 
whooping-cough.  Of  all  the  affections  cited,  this  is  without 
doubt  that  in  which  the  neurotic  element  is  most  marked. 
Both  the  respiratory  and  sympathetic  nerve-centres  are  dis- 
turbed in  its  early  stages,  while  the  pneumogastric  becomes 
implicated  before  the  local  causes  of  excitation  are  estab- 
lished, doubtless  indicating  a  primary  nervous  element  as  a 
predisposing  cause,  while  the  universal  presence  of  the  affec- 
tion in  forty  cases  of  hay  fever,  certainly  suggests  a  common 
systemic  cause  for  both  diseases — an  abnormally  sensitive 
nerve-centre  upon  which  the  element  of  contagion  or  the  irritant 
acts  with  effect. 

In  further  support  of  the  theory  of  systemic  predisposition, 
I  will  enumerate  a  few  of  the  cases  presenting  the  greatest 
evidences  of  heredity,  in  which  this  heredity  seems  to  have 
exerted  some  influence  in  the  production  of  the  so-called 
children's  diseases: 

Case  No.  14,  whose  mother,  uncle,  and  brother  have  hay 
fever,  while  his  grandfather  and  first  cousin  have  spasmodic 
asthma,  has  had  the  six  diseases  of  childhood.  No.  13's  two 
brothers  have  hay  fever ;  his  mother  and  sister  asthma ;  has 
had  five  (croup  omitted).  No.  15,  great  grandfather  and  first 
cousin,  hay  fever;  grandaunt  asthma;  has  had  five  (scarlatina 
omitted).  No.  31,  father,  hay  fever;  great  grandfather,  two 
great  uncles,  asthma ;  six  diseases,  while  all  those  presenting 
a  direct  maternal  or  paternal  heredity  of  hay  fever  and  rose 
cold,  with  one  exception,  have  had  the  six  diseases. 

Accepting  the  theory  as  conclusive,  as  far  as  the  question 
of  heredity  as  a  factor  in  the  causation  is  concerned,  a  new 
problem  suggests  itself :  In  those  cases  in  which  no  evidence 
of  heredity  appears,  what  is  the  origin  of  the  inordinate 
irritability?  In  other  words,  the  possibility  of  an  inherited 
liability  being  demonstrated,  can  it  be  acquired  independently 
of  heredity?  12 


178  DISEASES   OF   THE   ANTERIOR   NASAL    CAVITIES. 

Of  the  nineteen  cases  in  which  no  hereditary  history  could 
be  traced,  fifty-five  per  cent,  have  had  six  of  the  children's 
diseases  enumerated,  while  eighty-two  per  cent,  have  had  at 
least  four,  one  case  only  having  had  but  two.  In  the  three 
cases  which  presented  two  or  three  diseases,  I  find  that  in 
one  case,  there  is  a  subsequent  history  of  typhoid  fever, 
malarial  fever,  and  bronchitis,  all  occurring  before  the  first 
access  of  hay  fever ;  in  the  second,  migraine  was  a  frequent 
visitor  before  the  hay  fever  presented  itself;  while  in  the 
third,  a  child,  the  whooping-cough  and  chicken-pox  had  been 
very  severe. 

Taking  the  rationale  of  these  sixteen  cases,  with  a  history 
of  at  least  four  diseases,  all  of  them  presenting  marked 
neurotic  element,  is  it  not  probable  that  a  functional  derange- 
ment of  the  nerve-centres  resulted,  and  that  they  were  thus 
rendered  more  sensitive  to  influences  which,  had  they  been 
in  their  normal  state,  would  not  have  affected  them  1  Again, 
is  it  not  reasonable  to  suppose  that  in  the  first  exception,  the 
subsequent  diseases  accomplished  wThat  the  others  had  begun, 
debilitating  still  more  the  nerve-centres,  which  had  'already 
been  weakened  to  a  certain  degree  by  the  early  diseases  ? 
In  the  second  exception,  a  neurotic  element  is  apparent  in 
the  character  of  the  primary  disease,  wrhile  in  the  third  the 
virulence  of  the  diseases  must  certainly  have  borne  its  in- 
fluence on  the  secondary  results. 

Evidence  to  show  that  a  neurotic  element  is  an  essential 
part  of  the  affection,  can  easily  be  adduced  by  merely  in- 
vestigating the  origin  of  the  premonitory  symptoms  which 
are  present  in  a  number  of  cases.  It  would  certainly  be  very 
difficult  to  explain  their  presence,  were  we  to  overlook  the 
implication  of  the  nervous  system.  Among  the  forty  cases 
described,  may  be  found  one  young  man  who  complains  of 
"a  tickling  in  the  roof  of  the  mouth"  one  week  before  the 


PEEIODICAL  HYPEKESTHETIC   RHINITIS.  179 

onset;  another  patient  speaks  of  dull  pains  in  the  head  and 
back  two  weeks  before;  still  another  experiences  chills  and 
shuddering  ten  days  before  the  attack,  etc.,  while  a  large 
proportion  complain  of  palpebral  pruritus  from  two  to  ten 
days  before  the  nasal  symptoms  begin.  If  the  local  irritant 
is  the  only  cause,  why  does  the  respiratory  tract,  the  portion 
of  the  body  first  and  most  exposed  to  its  effects,  not  become 
immediately  influenced?  At  this  juncture  a  question  natu- 
rally suggests  itself:  What  then  induces  these  premonitory 
symptoms  f  Again  referring  to  the  cases,  we  will  find  that 
premonitory  symptoms  only  present  themselves  in  cases  in 
which  hay  fever  is  of  some  years'  standing.  As  the  accesses 
become  more  frequent,  the  system  habituates  itself  to  these 
annual  or  bi-annual  attacks,  and  periodicity  becomes  an  ele- 
ment of  the  case,  marked  in  proportion  with  the  degree  of 
impairment  of  the  nerve-centres.  As  an  illustrative  case,  I 
will  cite  that  of  a  medical  friend,  who,  in  a  letter  to  me, 
spoke  as  follows :  "  My  attacks  for  some  years  past  came  with 
much  regularity,  about  August  12th  to  14th.  On  these  dates 
this  year,  I  arranged  to  be  on  the  water,  on  Lake  Ontario  and 
the  St.  Lawrence  River,  and  entirely  escaped  everything  like 
sneezing  and  irritation  of  the  nose  and  eyes.  Still,  I  had  the 
usual  slightly  hot  and  irritable  skin,  then  an  eruption  of 
urticaria,  accompanied  by  disordered  stomach.  This  expe- 
rience is  precisely  the  same  as  in  1880,  except  that  then  I 
was  on  the  Atlantic,  on  shipboard."  In  this  case,  the  neurotic 
element  is  distinctly  shown  by  the  eruption  and  the  gastric 
disturbance,  while  periodicity  alone  can  explain  the  presence 
of  the  symptoms  at  the  precise  time  and  the  favorable  locali- 
ties in  which  they  manifested  themselves. 

As  to  the  nervous  symptoms  occurring  during  the  course  of 
an  attack,  I  am  more  disposed  to  consider  them  as  due  to 
reflex  irritation  from  the  local  trouble  than  as  originating 


180  DISEASES   OF   THE   AXTERIOR   NASAL    CAVITIES. 

primarily  in  the  nerve-centres.  During  the  access,  the  sus- 
ceptibility of  the  reflex  centres  is  developed  to  its  utmost 
extent,  and  sunlight,  a  draught  of  air,  etc.,  will  give  rise  to 
most  violent  symptoms,  which  would  not  be  the  case  at 
other  times. 

Accepting  the  above  as  conclusive  in  demonstrating  the 
presence  of  a  neurotic  element,  another  question  presents 
itself,  which,  left  unanswered,  would  expose  the  theory  to 
potent  criticism :  It  being  a '  recognized  fact  that  in  many 
individuals,  there  is  impairment  of  the  nerve-centres,  either 
due  to  heredity  or  to  disease,  fully  as  extensive  as  in  the 
worst  hay  fever  subject,  how  is  it  that  hay  fever  does  not 
manifest  itself  in  all  these  individuals  ?  To  answer  this,  the 
third  condition  comes  to  our  rescue :  In  persons  who  are  not 
subject  to  hay  fever,  the  nasal  mucous  membrane  is  either 
in  its  normal  state,  or,  if  diseased,  the  local  trouble  is  not  of 
a  nature  to  induce  an  abnormal  susceptibility  to  irritation, 
and  the  systemic  dyscrasia  is  not  awakened  to  action,  while 
in  the  hay  fever  patient,  an  hyperaesthetic  state  of  the 
mucous  membrane,  either  latent  or  due  to  local  disease,  is 
always  present,  furnishing  a  vulnerable  or  sensitive  area 
through  which  the  impaired  nervous  system  can  become 
influenced  by  the  external  irritant.  Both  systemic  and  local 
elements  must  exist  simultaneously  to  render  a  paroxysm 
possible. 

That  the  local  condition  of  the  nasal  mucous  membrane  is 
an  essential  factor  in  the  production  of  an  attack,  was  de- 
monstrated by  the  results  attained  with  a  treatment  in  which 
this  point  was  kept  in  view.  As  long  as  it  was  overlooked, 
all  efforts  to  conquer  the  disease  were  fruitless.  As  soon,  on 
the  contrary,  as  its  true  importance  was  duly  appreciated,  the 
chances  of  cure  became  greater  than  in  any  chronic  affection 
of  the  nose. 


PERIODICAL   HYPER^STHETIC   RHINITIS.  181 

In  July,  1883,  Dr.  J.  N.  Mackenzie,  of  Baltimore,  demon- 
strated that  "  there  exists  in  the  nose  a  well-defined  sensitive 
area  whose  stimulation  through  a  local  pathological  process, 
or  through  ab  extra  irritation,  is  capable  of  producing  an 
excitation  which  finds  its  expression  in  a  reflex  act,  or  in  a 
series  of  reflected  phenomena."  It  is  located  at  the  pos- 
terior end  of  the  inferior  turbinated  bones  and  the  corres- 
ponding portion  of  the  septum  (b  Fig.  53).  I  have  frequently 
been  able  to  verify  this  assertion,  not  only  in  the  production 
of  cough,  but  also  in  the  production  of  reflex  asthma,  in 
cases  in  which  a  predisposition  to  this  affection  existed. 
Professor  Hack,  of  Freiburg,  Germany,  has  also  demon- 
strated that  various  reflex  neuroses  originate  in  a  diseased 
condition  of  the  nasal  mucous  membrane.  Unlike  Dr.  John 
Mackenzie,  however,  he  locates  the  area  from  which  the 
reflex  symptoms  take  their  origin  at  the  anterior  extremity 
of  the  inferior  turbinated  bone  (c  Fig.  53),  and  advises  the 
removal  of  the  latter  for  the  cure  of  hay  fever.  In  cases 
in  which  there  was  anterior  hypertrophy,  without  a  history 
of  hay  fever,  I  have  not  succeeded  as  yet  in  producing  by 
local  pressure,  any  evidence  of  reflex  action,  while  in  some 
of  the  cases,  the  same  procedure  in  the  posterior  portion  of 
the  nasal  cavity  (Mackenzie's  area)  would  elicit  marked 
reflex  symptoms.  The  fact,  however,  that  the  terminal 
fibres  of  the  nasal  branches  of  the  spheno-palatine  ganglion 
and  of  the  nasal  branch  of  the  ophthalmic  meet  there  and 
form  quite  a  network,  certainly  verifies  the  view  held  by 
Hack,  as  to  its  being  a  reflex  area  of  importance.  In  cases 
of  hay  fever,  however,  I  have  almost  invariably  found 
marked  hypera3sthesia  in  this  portion  of  the  nasal  cavity, 
with  reflex  symptoms  in  the  superior  maxillary  region. 

In  addition  to  these  two  sensitive  areas,  practical  expe- 
rience in  a  large  number  of  cases  has  demonstrated  to  me 


182  DISEASES   OF   THE   ANTERIOR   NASAL   CAVITIES. 

that  a  third  area,  of  no  less  importance  than  that  of  Dr. 
J.  N.  Mackenzie,  exists  in  the  anterior  portion  of  the  nasal 
cavity,  near  the  angle  forming  the  anterior  boundary  of  the 
vestibule,  and  located  upon  the  nasal  wall,  as  well  as  on 
the  septum.  This  area  is  indicated  in  Fig.  53  by  the  letter 
(L  In  the  great  majority  of  persons  subject  to  hay  fever, 
if  not  in  all,  the  surface  of  the  membrane  in  this  locality 
is  exquisitely  sensitive,  and  the  contact  of  a  probe  provokes 
intense  itching  and  lachrymation. 


a,  Spheno-palatine  ganglion;  b,  posterior  area;  c,  middle  area;  d,  anterior  area;  e,  olfactory  bulb. 

It  thus  becomes  evident  that  there  are  in  the  nose  three 
areas  capable  of  producing  reflex  symptoms  in  the  course 
of  a  paroxysm  of  hay  fever,  and  that  the  three  combined 
form  the  key  of  the  local  nervous  element.  I  do  not  wish 
to  imply,  however,  that  the  three  areas  must  necessarily 
take  part  in  the  production  of  an  access ;  in  some,  only  one 
of  the  three  will  be  the  "  sensitive  spot ;"  in  another,  the 
posterior  and  middle  areas  will  be  involved,  etc.,  etc. 
Again,  a  difference  of  intensity  may  exist  in  the  degree  of 
hypera3sthesia ;  while  one  area  may  be  but  slightly  sensi- 
tive the  next  may  be  extremely  so.  In  cases  complicated 


PEKIODICAL   HYPERJESTHETIC   EHINITIS.  183 

with  asthma,  for  instance,  I  have  noticed  that  both  ante- 
rior and  posterior  areas  are  sensitive,  the  latter  being  prin- 
cipally so,  both  giving  rise  to  more  or  less  reflex  manifes- 
tations, but  that  when  the  paroxysms  are  uncomplicated, 
the  anterior  area  is  much  more  sensitive  than  the  pos- 
terior. 

An  explanation  of  the  origin  of  this  local  hypersesthesia 
would  not  be  difficult  did  it  involve  the  middle  and  poste- 
rior areas  of  the  nasal  cavity  only.  Here  it  may  be  caused 
by  most  of  the  affections  of  the  anterior  nasal  cavity,  from 
simple  chronic  rhinitis  down  to  nasal  polypi.  But  how 
can  we  explain  its  origin  in  the  anterior  portion  of  the 
cavity,  which  seldom  takes  part  in  the  diseases  to  which 
the  other  portions  are  liable  I  This  leads  us  to  the  dis- 
cussion of  another  question :  Can  hypenesthesia  of  the 
nasal  mucous  membrane  occur  idiopathically  or  is  a  patho- 
logical process  necessary  as  a  primary  cause? 

In  three  of  the  cases  which  have  so  far  come  under  my 
care,  examination  some  weeks  before  the  access  appeared, 
not  only  presented  the  cavities  in  their  normal  state, 
but  I  could  not  obtain  from  the  patient  any  indication  of 
the  presence  during  the  period  intervening  between  the  ac- 
cesses of  any,  even  temporary,  local  trouble.  Artificial  stim- 
ulation with  the  probe  to  ascertain  the  location  of  the 
hypersesthetic  spots,  as  first  suggested  by  Roe,  however, 
demonstrated  clearly  the  presence  of  several  of  them,  and 
in  one  case  gave  rise  to  a  number  of  reflex  symptoms.  It 
thus  appears  evident  that  a  healthy  membrane,  in  the  or- 
dinary sense  of  the  word,  can  become  hypersesthetic  with- 
out having  undergone  a  local  pathological  process,  and  this 
be  due  to  implication  of  the  nasal  nerve-supply  in  the 
general  neuraesthenia.  But  the  small  number  of  hay  fever 
sufferers  among  the  large  number  of  neurasthenic  people, 


18-4  DISEASES   OF   THE   ANTERIOR   NASAL   CAVITIES. 

makes  this  theory  hypothetical,  and  the  more  plausible  and 
less  eritieisable  one  of  local  chronic  disease  as  a  cause  of 
the  hypersesthesia  must  be  accepted.  In  the  three  cases 
in  which  no  disease  could  be  discovered,  then,  a  pathologi- 
cal process,  not  sufficiently  marked  to  be  appreciated  by 
ocular  inspection,  must  have  been  present.  As  far  as  the 
anterior  sensitive  area  is  concerned,  it  is  not  unlikely  that 
the  proximity  of  an  active  pathological  process  maintained, 
by  continuity  of  tissue,  a  latent  inflammatory  state  which 
caused  the  hypersesthesia. 

As  to  the  differentiation  of  one  irritant  from  another,  I 
believe,  with  Dr.  J.  N.  Mackenzie,  that  it  resides  in  the 
nerve-centres  themselves.  Their  abnormal  state  renders 
them  much  more  susceptible  to  the  effects  of  external  in- 
fluences, and  their  discriminating  power  is  increased  in  pro- 
portion. Let  there  be  in  a  certain  subject  any  unusual 
susceptibility  to  any  particular  substance  or  substances,  this 
will  be  increased  in  proportion  to  the  degree  of  disturbance 
in  the  nerve-centres,  the  result  being  an  exalted  reflex  man- 
ifestation. This  peculiar  susceptibility  to  certain  substances 
is  well  exemplified  by  the  violent  coryza  brought  on  in  some 
persons  by  ipecacuanha.  So  sensitive  are  some  to  its  effects, 
that  a  few  moments  spent  in  a  drug  store  are  sufficient  to 
cause  an  attack. 

A  number  of  secondary  circumstances  seem  to  exert  some 
influence  in  the  production  of  the  affection,  the  principal 
of  which  is  nationality.  It  is  a  strange  fact  that  the  Ameri- 
cans and  the  English  are  the  principal  sufferers.  It  might 
not  be  amiss  to  suggest  that  these  are  the  only  two  great 
tea-drinking  nations,  and  that  this  beverage  may  exert  a 
depressing  influence  on  the  nerve-centres,  and  aggravate  an 
inherited  or  acquired  neursesthenia. 

The   affection  seems  to  be  most  frequent   among  people 


PEEIODICAL  HYPER^STHETIC  RHINITIS.  185 

of  education  and  those  in  comfortable  circumstances,  or 
whose  occupation  is  sedentary.  This  may  be  due  to  a  lack 
of  wholesome  exercise  in  the  open  air,  a  fact  which  I  have 
been  able  to  appreciate  in  the  great  majority  of  cases. 

Heredity  has  been  shown  to  exert  great  influence  in  the 
etiology  of  the  affection,  thirty-seven  per  cent,  of  the  forty 
cases  alluded  to  in  the  first  part  of  this  essay,  having  rela- 
tives who  are  sufferers  of  either  rose  cold  or  hay  fever, 
while  asthma,  which  is,  as  shown,  a  predisposing  cause,  is 
present  in  eighteen  per  cent.  more. 

The  affection  seems  to  be  somewThat  more  frequent  in  men 
than  women,  the  use  of  to~bacco  and  other  pernicious  habits 
in  the  former  being  possibly  accountable  for  the  difference. 

Pathology. — An  important  point  in  connection  with  the 
curative  measures  to  be  adopted,  is  a  proper  recognition  of 
the  fact,  that  each  nasal  cavity  is  divided  into  two  regions 
which  have  distinct  physiological  functions, — the  olfactory 
region,  in  which  the  sense  of  smell  is  located,  and  the  res- 
piratory region,  the  function  of  which  is  to  purify  the  air 
of  foreign  substances,  besides  furnishing  it  with  the  neces- 
sary moisture  and  warmth  before  it  reaches  the  lungs.  As 
can  be  seen  in  Fig.  53,  the  filaments  of  the  olfactory  nerve 
cover  the  superior  turbinated  and  the  upper  third  of  the 
middle  turbinated  bone.  They  also  cover  the  correspond- 
ing portion  of  the  septum.  The  upper  part  of  the  nasal 
cavity  is  thus  devoted  entirely  to  the  sense  of  smell  and 
not  involved  in  the  pathological  etiology  of  hay  fever. 

The  respiratory  region  which  includes,  as  already  stated  in 
the  chapter  on  anatomy,  all  the  surfaces  below  the  olfac- 
tory, is  under  the  control  of  vaso-motor  nerves  of  the  sym- 
pathetic system,  and  is  exceedingly  sensitive  to  local  or 
peripheral  irritating  causes.  This  sensitiveness,  however, 
does  not  reside  in  the  vaso-motor  supply,  which  is  only  a 


186  DISEASES   OF   THE   ANTERIOR  NASAL   CAVITIES. 

secondary  factor  in  the  production  of  turgescence,  but  in 
the  terminal  filaments  of  the  sensory  nerves  distributed 
over  the  surface  of  the  membrane.  A  brief  allusion  has 
already  been  made  to  these,  when  speaking  of  the  different 
hyperaesthetic  areas,  but  they  were  not  sufficiently  described 
to  render  a  clear  outline  of  the  pathological  process  pos- 
sible. Commencing  with  the  posterior  area,  we  find  that 
the  membrane  of  that  location  is  supplied  by  several 
branches  of  the  spheno-palatine  ganglion,  which  enter  the 
back  part  of  the  nasal  fossa  by  the  spheno-palatine  fora- 
men. Besides  its  motor  and  sensory  roots,  the  spheno- 
palatine  ganglion  possesses  a  sympathetic  root,  which  is 
derived  from  the  carotid  plexus  through  the  vidian,  thus 
forming  a  well-defined  connecting  link  between  the  nasal 
membrane  and  the  sympathetic  system. 

In  the  production  of  the  reflex  symptoms  peculiar  to  the 
posterior  area,  cough  and  asthma,'  the  impression  is  conse- 
quently transmitted  from  the  posterior  end  of  the  infe- 
rior turbinated  bone  or  the  corresponding  portion  of  the 
septum,  to  the  spheno-palatine  ganglion ;  from  that  to  the 
carotid  plexus,  which  is  closely  connected  with  the  poste- 
rior pulmonary  plexus,  formed  not  only  by  the  branches 
of  the  sympathetic  but  also  by  some  from  the  pneu- 
mogastric,  and  finally  to  the  ramifications  of  the  air-tubes 
through  the  ultimate  filaments  of  the  former,  which  are 
lost  in  the  bronchial  mucous  lining.  In  many  cases,  how- 
ever, the  asthma  is  not  due  to  reflex  action,  but  to  the 
gradual  extension  of  the  catarrhal  inflammation  from  the 
nasal  membrane,  down  along  the  pharynx,  trachea  and 
bronchi.  In  these  cases,  the  asthmatic  symptoms  only 
manifest  themselves  some  time  after  the  onset  of  the  par- 
oxysm. In  both  varieties  the  exciting  cause  and  the  ulti- 
mate results  are  the  same,  but  in  the  one  the  link  between 


PEKIODICAL    HYPER^SSTHETIC    RHINITIS.  187 

them  is  the  nervous  system,  while  in  the  other  it  is  the 
mere  continuity  of  tissue.  The  frequently  complained  of 
symptom,  itching  at  the  roof  of  the  mouth,  is  readily  ex- 
plained by  the  presence  of  a  large  number  of  branches 
which  emanate  directly  from  the  spheuo-palatine  ganglion 
and  are  distributed  throughout  the  membrane  covering  the 
inferior  surface  of  the  hard  and  soft  palate. 

The  middle  area  being  formed  by  the  terminal  fibres  of 
the  branches  constituting  the  posterior  and  anterior  areas, 
irritation  over  it  may  give  rise  to  any  of  the  reflex  symp- 
toms which  the  two  former  occasion. 

The  anterior  area  includes  the  nasal  nerve,  one  of  the 
principal  branches  of  the  first  division  of  the  fifth  pair, 
the  ophthalmic,  which  supplies  the  eyeball,  the  lachrymal 
gland,  the  mucous  lining  of  the  eye  and  nose,  and  the  in- 
tegument and  muscles  of  the  eyebrow  and  forehead.  This 
distribution,  and  the  fact  that  the  ophthalmic  is  a  sensory 
nerve,  explains  readily  how  a  pathological  condition  in- 
volving the  nasal  nerve  may  produce  so  many  varied  symp- 
toms. In  the  production  of  lachrymation  and  palpebral 
pruritus,  we  have  the  lachrymal  branch,  which  supplies 
not  only  the  lachrymal  sac,  but  also  the  conjunctiva.  In 
addition  to  this  cause,  however,  closure  of  the  tear  duct 
certainly  contributes  greatly  to  the  profuse  lachrymation. 
The  photophobia  also  finds  an  easy  explanation,  if  we  con- 
sider the  communication  existing  between  the  first  division 
of  the  fifth  pair  and  the  ophthalmic  or  ciliary  ganglion,  the 
filaments  of  which  are  distributed  to  the  ciliary  muscle  and 
the  iris.  If  we  couple  this  with  the  fact  that  the  pupil  is 
dilated  when  the  eyes  are  implicated  in  the  paroxysm,  we 
can  understand  how  exposure  to  sunlight  can  aggravate 
symptoms  of  the  affection,  and  appreciate  the  pathological 
verification  which  it  furnishes.  The  conjunctiva,  however, 
is  often  irritable  per  se. 


188  DISEASES   OF   THE   ANTERIOR   NASAL   CAVITIES. 

In  accordance  with  these  views,  the  production  of  a  par- 
oxysm may  be  briefly  described  as  follows:  A  given  irri- 
tant coming  in  contact  with  the  hypera3sthetic  nasal  mem- 
brane in  a  neurasthenic  subject,  the  impression  made  on 
the  former  is  transmitted  through  the  afferent  fibrillsB  of 
the  nearest  set  of  sympathetic  ganglia  to  those  ganglia,  and 
returned  by  them  to  the  vaso-motor  nerves  of  the  mem- 
brane. The  result  is  the  same  as  in  acute  rhinitis — a  pri- 
mary contraction  of  the  vessels  followed  by  dilatation,  the 
venous  sinuses  or  corpora  cavernosa  becoming  filled  with 
venous  blood  and  remaining  distended.  Violent  sneezing 
occurs  as  soon  as  the  membrane  of  the  septum  and  that 
over  the  turbinated  bones  touch,  and  reflex  asthma  presents 
itself  if  the  distention  is  sufficiently  great  in  the  posterior 
area  to  cause  pressure  against  the  septum.  In  the  anterior 
area,  the  manifestations  are  not  local,  but  occur  in  the 
parts  which  are  in  direct  nervous  communication  with  it. 
We  thus  have  lachrymation,  photophobia,  headache,  facial 
and  palpebral  pruritus,  and  so  forth.  If  the  distention  is 
great  in  the  middle  area  and  nowhere  else,  we  may  have 
the  whole  train  of  symptoms,  both  anterior  and  posterior 
areas  being  involved,  while  implication  of  the  posterior 
area  will  give  rise  to  asthma  if  there  is  sufficient  turges- 
cence  to  cause  pressure  against  the  septum,  and  if  the 
asthmatic  tendency  exists  in  the  patient.  As  to  the  general 
systemic  disturbances  present  in  connection  with  the  head 
symptoms,  they  are  easily  accounted  for  by  the  momentary 
increase  of  the  abnormal  excitability  of  the  nerve-centres. 

In  my  opinion,  a  paroxysm  brought  on  by  peripheral  irri- 
tation, exposure  to  draughts,  wind,  dampness,  etc.,  or  occur- 
ring as  a  reflex  manifestation  from  other  parts  of  the  body 
in  an  abnormal  state  at  other  times  than  in  the  hay  fever 
season,  cannot  be  considered  as  hay  fever.  It  is  an  attack 


PERIODICAL   HYPEE^STHETIC   RHINITIS.  189 

of  acute  coryza,  due  to  the  fact  that  the  nasal  mucous 
membrane  receives  its  vase-motor  innervation  from  a  gan- 
glion which  is  the  part  of  least  resistance  in  the  patient's 
economy,  and  which  does  not  require  a  special  agent  to 
become  influenced. 

Symptoms. — The  symptoms  of  hay  fever  may  be  limited  to 
those  of  a  mild  coryza  and  last  only  a  few  days,  or  they  may 
assume  such  violent  form  as  to  cause  the  patient  great  suf- 
fering. The  attack  usually  begins  with  a  sensation  of  itching 
in  the  nostrils,  which  soon  becomes  very  intense,  and  causes 
violent  and  prolonged  sneezing.  A  pricking,  burning  sensa- 
tion in  the  inner  canthi,  followed  by  profuse  lachrymation, 
may  accompany  this  symptom,  or  constitute  the  first  evi- 
dence of  the  access.  Very  soon  the  nose  becomes  occluded 
through  turgescence  of  its  lining  membrane,  and  respiration 
through  it  is  practically  impossible.  A  watery  discharge 
appears,  which  soon  becomes  very  profuse,  and  its  strongly 
alkaline  character  causes  it  to  irritate  the  nostrils  and  the 
upper  lip,  sufficiently  sometimes  to  give  rise  to  painful  ex- 
coriations. Violent  sneezing  may  begin  at  once,  or  occur 
when  the  watery  discharge  begins  to  trickle  down  along  the 
intra-nasal  walls,  and  the  patient  makes  futile  efforts  by  im- 
moderate use  of  the  handkerchief,  to  clear  the  nose  of  the 
cause  of  irritation  and  obstruction.  Chilly  sensations,  frontal 
headache,  tinnitus  aurium,  loss  of  smell  and  taste,  violent 
itching  at  the  roof  of  the  mouth,  pain  over  the  bridge  of 
the  nose,  facial  pruritus,  and  general  symptoms,  such  as 
slight  pyrexia,  urticaria,  disordered  stomach  and  flatulence, 
are  among  the  possible  accompaniments  of  this  stage. 

As  the  affection  progresses,  the  nasal  secretion  assumes 
more  of  a  mucoid  character,  becoming  at  times  muco-puru- 
lent.  The  conjunctiva  may  become  greatly  inflamed,  and 
photophobia  and  marked  chemosis  follow,  rendering,  in  some 
cases,  a  prolonged  stay  in  a  dark  room  necessary. 


190  DISEASES   OF   THE   ANTERIOR   NASAL   CAVITIES. 

Premonitory  symptoms  are  present  in  a  small  proportion 
of  the  cases,  especially  in  those  of  long  standing.  Frontal 
headache,  general  malaise,  chilly  sensations,  and  itching  at 
the  roof  of  the  mouth  and  eyes,  occurring  from  two  days  to 
two  weeks  before  the  attack,  are  among  those  most  fre- 
quently complained  of.  Asthma  may  occur  as  a  complica- 
tion of  the  affection,  or  as  its  only  symptom.  In  the  former 
case,  it  may  present  itself  any  time  during  the  course  of  the 
disease ;  in  the  latter,  it  manifests  itself  suddenly  as  soon 
as  the  irritating  agent  is  inhaled.  In  the  majority  of  cases, 
however,  it  begins  a  few  days  after  the  primary  nasal  symp- 
toms have  shown  themselves,  and  as  soon  as  these  become 
marked.  A  feeling  of  soreness  in  the  region  of  the  pharynx 
is  experienced,  followed  shortly  after  by  hoarseness,  slight 
cough,  scanty  expectoration,  and  a  feeling  of  constriction 
about  the  chest,  and  the  asthma  comes  on  insidiously,  gradu- 
ally increasing  in  intensity  as  the  disease  advances.  It  is 
generally  much  worse  at  night  than  in  the  day-time,  relief 
coming  on  with  the  dawn  of  the  day.  In  some  cases  it 
ceases  with  the  nasal  symptoms,  or  soon  after ;  in  others, 
and  this  forms  the  majority,  it  lasts  much  longer,  prolonging 
the  suffering  of  the  patient  over  weeks  and  even  months. 

The  affection  presents  itself  twice  in  the  year  in  some 
individuals,  while  in  others  it  either  occurs  in  May  or  June, 
or  during  the  last  two  weeks  of  August  or  early  in  Septem- 
ber. The  summer  variety,  generally  called  "rose  cold,"  is 
not  as  a  general  thing  as  severe  as  the  autumnal  variety  or 
"  hay  fever,"  and  does  not  last  as  long.  Subjects  of  the  dis- 
ease can  in  almost  every  instance  predict  the  exact  day,  and 
sometimes  the  hour,  of  the  onset  of  the  expected  attack. 

Curative  Treatment. — The  first  indication  in  the  curative 
treatment  of  hay  fever  is  to  ascertain  by  careful  examina- 
tion of  the  nasal  chambers,  whether  the  condition  which  gave 


PEKIODICAL   HYPER^ESTHETIC   RHINITIS.  191 

rise  to  the  hyperaesthesia  is  sufficiently  marked  to  receive 
special  attention.  In  the  great  majority  of  cases,  a  simple 
chronic  rhinitis  exists  with  a  tendency  to  frequent  or  perma- 
nent turgesceuce  of  the  mucous  membrane.  In  others  w<« 
have  true  hypertrophy,  involving  either  the  anterior  or  pos- 
terior portions  of  the  nasal  cavities,  or  both.  Occasionally 
we  find  polypi,  which  occlude  more  or  less  one  or  both  cavi- 
ties, while  a  deviated  or  thickened  septum  may  keep  up  a 
marked  irritation  and  constitute  a  serious  obstacle  to  a  sub- 
sequent thorough  treatment.  When  these,  or  any  other  ab- 
normal condition  compromising  mechanically  the  lumen  of 
the  cavities,  are  present,  they  should  first  receive  attention, 
and  the  nasal  cavities  returned  as  nearly  as  possible  to  their 
normal  state.  If  the  treatment  employed  be  one  of  a  de- 
structive nature,  the  organic  changes  induced  by  it  in  the 
mucous  membrane  proper  will  often  be  sufficient  to  annul 
its  hypersesthesia.  This  was  exemplified  by  the  cases  re- 
ported by  Daly,  Roe  (first  paper),  in  two  of  the  first  reported 
by  me,  and  in  several  reported  by  Dr.  Harrison  Allen.  In  a 
large  proportion  of  patients,  however,  it  does  not  suffice,  and 
immunity  from  the  disease  can  only  be  expected  after  each 
sensitive  spot  has  been  thoroughly  cauterized. 

Organic  alteration  of  the  surface  of  the  membrane,  first 
proposed  by  me  in  December,  1883,  can  be  induced  by  the 
application  of  galvano-cautery  or  of  caustic  acids.  Each 
sensitive  spot  must  be  ascertained  and  treated  with  the 
agent  used  until  the  exaggerated  sensitiveness  is  replaced 
by  the  normal  sensation  of  contact.  When  the  galvano- 
cautery  is  to  be  used,  it  is  very  essential  to  have  a  battery 
powerful  enough  to  cause  the  platinum  loop  to  suddenly 
attain  white  heat,  so  as  to  avoid  the  pain  caused  by  the 
gradual  increase  of  the  temperature,  and  prevent  prolonged 
radiation.  This  condition  being  fulfilled,  we  require  a  loop, 


192 


DISEASES   OF   THE   ANTERIOR   NASAL   CAVITIES. 


which,  upon  being'  entered  into  the  nasal  cavity,  will  be 
sufficiently  blunt  at  the  point  and  edges  not  to  scratch  or  cut 
the  mucous  membrane,  when  gently  passed  over  it.  I  have 
found  the  tip  shown  in  Fig.  54,  which  resembles  an  ordinary 
cautery  knife,  but  is  more  rounded  at  the  point  and  somewhat 
broader,  most  satisfactory.  It  can  be  easily  introduced  in  all 
the  sinuosities  of  the  fossae. 


The  cautery  knife  applied  to  the  anterior  area,     c,  middle  area ;   a,  posterior  area;  d  and  e,  sensitive 

surface  of  middle  turbinated  body. 

The  nasal  cavity  being  properly  dilated  and  illuminated, 
the  cautery  knife  is  introduced  gently  and  applied  flatwise 
to  the  anterior  area  as  indicated  in  the  cut.  If  the  part  is 
not  sensitive,  the  patient  will  not  wince,  the  sensation  being 
hardly  more  than  a  slight  itching.  If  it  is  hypersesthetic,  a 


PERIODICAL   HYPER^STHETIC   RHINITIS.  193 

feeling  of  intense  itching  or  burning  will  be  complained  of, 
followed,  in  some  cases,  by  profuse  lachrymation.  As  soon 
as  the  evidences  of  abnormal  sensitiveness  appear,  care 
should  be  taken  not  to  move  the  platinum  tip,  and  the  circuit 
being  closed,  the  metal  singes  the  spot,  destroying  the  super- 
ficial nervous  filaments.  If  the  platinum  becomes  white  hot 
immediately,  comparatively  little  if  any  pain  will  be  experi- 
enced, but  the  contrary  will  certainly  be  the  case,  if  a  weak 
current,  or  a  knife  so  thin  that  the  nasal  mucus  will  prevent 
it  from  becoming  heated  rapidly,  is  used. 

One  spot  being  cauterized,  another  sensitive  spot  is 
searched  for  by  gently  passing  the  loop  over  the  surface 
until  the  patient  complains  of  the  sensations  experienced 
before,  when  the  current  is  again  applied.  In  this  manner 
the  entire  respiratory  area  should  be  gone  over,  until  the 
instrument  can  be  applied  to  any  part  of  the  membrane 
without  exciting  reflex  symptoms  or  causing  the  violent 
itching  or  burning,  which  the  patient  soon  learns  to  recognize. 

The  pain  accompanying  these  applications  varies  according 
to  the  degree  of  heat  employed.  White  heat,  which  cauter- 
izes in  an  instant,  destroys  the  nerve  filaments  before  they 
have  time  to  convey  the  sensation  of  pain  to  the  nerve-cen- 
tres. Cherry  heat  causes  some  pain,  while  black  heat  is  ex- 
ceedingly painful.  White  heat,  therefore,  should  always  be 
employed  for  superficial  applications. 

The  cauterizations  should  always  be  begun  in  the  anterior 
portions  of  the  nasal  cavity  (except  when  reflex  asthma  is 
present  as  a  complication  of  the  affection,  for  reasons  which 
will  be  explained  later  on),  so  that  the  anterior  hyperaesthesia 
will  not  be  present  when  the  posterior  parts  are  examined, 
and  thus  conceal  the  sensitiveness,  or  convey  a  wrong  idea  as 
to  its  location.  The  septum  should  be  as  carefully  examined 
as  the  turbinated  bones,  and  any  spot  of  even  doubtful  hyper- 
aesthesia  cauterized.  13 


194  DISEASES    OF   THE   ANTERIOR   NASAL    CAVITIES. 

Three  or  four  spots  in  each  cavity  can  be  cauterized  at 
one  sitting,  and  it  is  best  to  locate  them  some  distance  apart. 
A  sensitive  spot  being  found  in  the  upper  part  of  the  ante- 
rior area,  for  instance,  and  cauterized,  the  next  spot  should 
be  looked  for  in  the  lower  part  of  the  septum,  etc.  In  short, 
the  object  should  be  to  avoid  large  superficial  abrasions, 
numerous  small  ones  healing  much  faster  and  producing 
no  disagreeable  after-effects.  In  the  great  majority  of 
cases,  a  few  minutes  after  the  applications  are  made,  all 
annoying  sensations  are  passed,  and  the  patient  can 
return  to  his  business  without  fear  of  being  in  the  least 
troubled.  In  some  few,  however,  the  membrane  swells  for  a 
while,  and  the  patient  may  experience  difficulty  in  breathing 
through  the  nose.  When  such  is  the  case,  one  nostril  should 
be  treated  at  each  visit,  so  as  to  preserve  for  the  patient  the 
patency  of  the  other,  and  thus  insure  him  comparatively  free 
respiration. 

In  two  cases,  so  far,  the  applications  were  followed  by  an 
attack  of  coryza,  accompanied  by  reflex  symptoms.  In  one 
case  it  lasted  ten  hours,  in  the  other  it  continued  about 
twenty-four. 

The  membrane  covering  the  middle  turbinated  bone  does 
not  seem  to  enter  the  process  of  resolution  after  galvano- 
cautery  applications,  as  readily  as  the  other  portions  of  the 
respiratory  region.  In  three  cases  in  my  practice,  oedematous 
inflammation  took  place,  which  caused  me  to  mistake  the 
overhanging  grape-like  protuberance  for  a  polypus.  In  one 
case  I  snared  it  off,  causing  immediate  recovery;  the  two 
others  were  left  to  themselves,  and  disappeared  after  a  few 
weeks.  Fortunately,  the  limited  innervation  of  the  surface 
of  the  middle  turbinated  membrane,  renders  but  few  applica- 
tions necessary,  and  they  should  be  made  sufficiently  far 
apart  to  insure  complete  resolution  after  each  sitting. 


PERIODICAL   HYPER^ESTHETIC   RHINITIS.  195 

Important  in  this  connection  is  the  proper  topographical 
recognition  of  the  olfactory  membrane,  which  includes  the 
upper  third  of  the  middle  turbinated  body.  Care  should  of 
course  be  taken  not  to  cauterize  it,  and  to  limit  the  applica- 
tions over  the  turbinated  bone  to  its  lower  half.  With  this 
precaution,  no  danger  to  the  sense  of  smell  need  be  appre- 
hended. 

The  number  of  applications  required  to  render  immunity 
positive,  depends  of  course,  upon  the  number  of  sensitive 
spots.  With  some,  five  sittings  are  sufficient,  while  in  the 
majority  of  patients  from  fifteen  to  twenty  are  required,  each 
from  three  days  to  one  week  apart,  the  length  of  the  interval 
depending  upon  the  rapidity  with  which  resolution  of  each 
cauterized  spot  takes  place. 

When  the  physician  is  not  possessed  of  galvano-cautery  in- 
struments, acids  may  be  used  instead.  Chromic  acid  would 
be  the  best  of  any,  were  it  not  for  the  danger  of  general  tox- 
aemia following  its  application  over  comparatively  large  sur- 
faces. Glacial  acetic  acid,  with  which  I  treated  my  first  cases 
in  the  spring  of  1881,  is  tha  most  satisfactory  in  every  way 
except  one — the  pain  its  application  gives  rise  to,  on  account 
of  the  quantity  which  has  to  be  used.  This  fact,  however, 
can  in  a  great  measure  be  corrected  by  dissolving  in  it  hydro- 
chlorate  of  cocaine  to  saturation.  Another  feature  character- 
izing its  use,  is  the  turgescence  which  takes  place  after  each 
application,  as  stated  when  speaking  of  the  treatment  of  an- 
terior hypertrophies.  The  hydrochlorate  of  cocaine  seems 
also  to  influence  this  result,  by  limiting  the  inflammation 
markedly  and  advancing  resolution.  Dr.  Beverly  Robinson, 
of  New  York,  has  reported  good  results  with  applications  of 
pure  carbolic  acid.  Unlike  when  it  is  applied  to  other  parts  I 
found  that  this  acid  caused  much  pain,  besides  imparting  its 
well-known  odor,  and  I  therefore  discontinued  its  use. 


DISEASES   OF   THE   ANTERIOR   NASAL   CAVITIES. 

Nitric  acid  should  never  be  used,  except  for  the  reduction 
of  hypertrophies  as  described. 

For  the  application  of  glacial  acetic  acid,  the  instrument 
shown  in  Fig.  54  will  be  found  very  satisfactory.  It  consists 
of  two  probes,  shaped  like  Bosworth's  (Fig.  31),  in  close  appo- 
sition, their  surfaces  being  so  flattened  as  to  render  their 
contact  perfect.  One  of  the  probes  is  fastened  to  the  handle 
and  is  furnished  with  a  number  of  shallow  holes,  a  distance  of 
one-half  inch  along  the  inner  surface  of  its  extremity,  so  that 
a  drop  of  acid  will  be  retained  when  the  other  probe  is  placed 

Fig-  54 


Author's  glacial  acetic  acid  applicator. 

over  it.  The  latter  having  free  longitudinal  motion,  can  be 
moved  freely  along  the  other  by  means  of  a  finger  lever,  thus 
uncovering  at  will  the  acid-covered  surface.  The  two  probes 
are  so  arranged  that  they  can  be  rotated  together  on  their 
axis,  so  that  the  acid-covered  surface  can  be  made  to  face  any 
direction.  Their  broad  ends  being  of  silver,  the  acid  does 
not  affect  them. 

The  manipulation  of  this  instrument  is  precisely  the  same 
as  that  of  the  galvano-caustic  knife.  Being  introduced  into 
the  cavity,  a  sensitive  spot  is  searched  for  with  both  probes 
in  apposition,  and  as  soon  as  it  is  found,  the  finger  lever  is 
depressed  and  the  acid  probe  being  uncovered,  the  spot  is 


PERIODICAL   HYPER^ESTHETIC   RHINITIS.  197 

cauterized.  The  finger  lever  is  then  allowed  to  raise,  and  the 
instrument  can  be  withdrawn  without  cauterizing  any  other 
surface.  Care  should  be  taken  to  cleanse  the  instrument 
carefully  before  entering  it  into  the  nose,  lest  some  acid 
remain  over  its  surface. 

As  to  the  period  when  the  applications  should  be  made, 
I  am  of  the  opinion  that  the  treatment  should  be  begun  at 
least  two  months  before  the  expected  attack.  There  is  suf- 
ficient time  left  then,  to  annul  all  the  hypera3sthetic  spots 
(in  the  great '  majority  of  cases)  without  having  to  crowd 
the  applications  together,  an  unsatisfactory  procedure,  since 
the  inflammation  is  likely  to  impair  the  abnormal  hyper- 
sesthesia  and  prevent  proper  recognition  of  the  sensitive 
spots. 

In  three  cases  so  far,  I  have  been  able  to  arrest  the 
paroxysm  from  one  to  three  weeks  after  it  had  begun, 
and  when  it  was  at  its  height.  This  result,  however, 
cannot  be  expected  in  every  case,  but  the  applications 
are  beneficial  in  all,  and  reduce  in  a  marked  manner  the 
intensity  of  the  paroxysm  and  its  duration.  Of  seven 
cases  treated  last  season  in  the  midst  of  the  hay  fever, 
three  were  entirely  relieved,  three  were  much  benefited, 
and  the  seventh  was  enabled  to  return  to  his  business, 
from  an  imprisonment  in  a  dark  room.  Although  his 
sufferings  were  much  abated,  they  continued  until  the 
end  of  his  usual  six  weeks. 

When  the  treatment  is  begun  at  the  proper  time,  i.e., 
several  weeks  before  the  paroxysm,  its  success  depends  en- 
tirely upon  the  thoroughness  with  which  both  nasal  cavities 
have  been  relieved  of  their  sensitive  spots.  An  insufficient 
number  of  applications,  or  a  timid  patient,  are  as  likely  to 
prevent  a  radical  cure,  as  a  thorough  treatment  in  a  plucky 
patient  is  certain  to  be  rewarded  with  permanent  immunity. 


198  DISEASES   OF   THE   ANTERIOR   NASAL   CAVITIES. 

An  important  point  in  connection  with  the  results  of  im- 
perfect cauterization  is  that  however  limited  the  number  of 
applications  may  be,  the  benefit  produced,  as  far  as  the 
nasal  symptoms  are  concerned,  is  proportionate  with  that 
number,  and  with  the  thoroughness  with  which  they  are 
performed.  When  but  a  limited  number  of  applications  are 
made  before  the  period  of  attack,  the  onset  of  the  parox- 
ysm is  retarded,  which  naturally  curtails  the  duration  of 
the  disease,  while  its  intensity  is  reduced. 

Again,  when  reflex  asthma  is  a  complication  of  the  affec- 
tion, and  an  insufficient  number  of  applications  have  been 
made,  this  symptom  is  likely  to  appear  as  the  sole  expres- 
sion of  the  paroxysm,  the  head  symptoms  being  absent,  or 
if  present,  exceedingly  mild.  This  is  doubtless  due  to  the 
fact  that  the  first  applications  being  made  anteriorly,  the 
sensitive  spots  in  the  anterior  and  middle  areas  are  more 
or  less  deprived  of  their  hypera3sthesia  (the  presence  and 
intensity  of  the  head  symptoms  depending  upon  the  thor- 
oughness with  which  this  is  done),  and  the  posterior  area 
being  only  cauterized  towards  the  end  of  the  treatment, 
the  symptoms  which  are  secondary  to  its  irritation  present 
themselves. 

A  conclusion  which  I  have  come  to  lately,  and  which  is 
borne  out  in  the  above  cases  and  by  close  observation  in 
all  the  others,  is  that  when  reflex  asthma  exists  as  a  com- 
plication of  the  head  symptoms,  a  greater  number  of  appli- 
cations are  required  than  when  it  does  not,  and  that  im- 
munity from  all  the  symptoms  can  only  be  obtained  when 
all  three  of  the  sensitive  areas  have  been  thoroughly  treated, 
the  treatment  of  the  posterior  area  being  such  as  to  limit 
the  inordinate  power  of  turgescence,  which  is  always  present 
when  true  hypertrophy  does  not  exist.  In  accordance  with 
this  view,  I  now  direct  my  attention  first  to  the  posterior 


PERIODICAL   HYPERJESTHETIC    RHINITIS.  199 

area,  when  reflex  asthma  exists,  employing  chromic  acid, 
galvano-cautery,  or 'the  snare  ecraseur  as  needs  be.  This 
is  greatly  facilitated  by  annulling  the  hyperasthesia  of  the 
anterior  and  middle  areas  with  a  four  per  cent,  solution  of 
cocaine. 

In  the  cases  in  which  asthma  is  the  only  symptom,  this 
procedure,  when  thoroughly  conducted,  will  often  suffice  to 
cure  the  affection,  even,  sometimes,  when  mild  head  symp- 
toms are  present  (these  being  due  to  implication  of  what 
terminal  filaments  of  the  nasal  nerve  may  extend  in  the 
sensitive  region),  but,  as  these  cases  are  rare,  applications 
to  the  anterior  and  middle  areas  are  nearly  always  neces- 
sary. 

Again,  a  mild  case  of  hay  fever,  complicated  with  reflex 
asthma,  may  be  due  solely  to  hyperassthesia  of  the  middle 
area,  and  be  cured  by  a  treatment  limited  to  it.  Here,  the 
asthma  is  due  to  the  turgescence  of  the  posterior  area  oc- 
curring as  a  result  of  the  inflammatory  process,  while  the 
head  symptoms  are  induced,  as  just  stated,  through  impli- 
cation of  the  nasal  nerve  in  the  hypersesthetic  region.  I 
am  of  the  opinion,  however,  that  it  is  always  best  to  in- 
clude the  posterior  ends  of  the  turbinated  bodies  in  the 
treatment. 

As  stated  under  the  heading  of  Pathology,  catarrhal 
asthma,  which  occurs  late  in  the  history  of  the  affection, 
is  much  more  frequently  met  with  than  the  reflex  variety, 
which  comes  on  as  soon  as  the  Schneiderian  membrane 
has  become  sufficiently  turgid,  through  the  local  inflamma- 
tion, to  induce  pressure  against  that  of  the  septum.  Being 
due  to  extension  of  the  inflammation  by  continuity  of  tissue, 
it  can  only  present  itself,  provided  the  nasal  symptoms 
take  place,  and  prevention  of  the  latter  will  obviously 
deprive  the  asthma  of  its  primary  cause  and  prevent  it. 


200  DISEASES    OF   THE   ANTERIOR   NASAL   CAVITIES. 

When  the  membrane  is  free  from  hypertrophies,  etc.,  cauter- 
ization of  the  sensitive  spots,  whether  these  be  situated  in 
the  anterior,  middle,  or  posterior  areas,  will  therefore  be 
sufficient  to  prevent  both  head  symptoms  and  asthma,  a 
fact  so  far  demonstrated  in  six  cases. 

When  the  head  symptoms  solely  characterize  the  ac- 
cesses, the  greatest  hypera3sthesia  will  be  found  in  the 
anterior  area,  which  will  of  course  require  the  brunt  of 
the  treatment.  Any  other  sensitive  spot,  however,  should 
also  be  effectively  cauterized. 

After-effects  of  the  local  treatment. — Although  the  number 
of  cases  treated  so  far  has  been  rather  large,  I  have  not 
had  to  regret  any  ill-effect  occurring  as  a  result  of  the 
treatment.  The  sense  of  smell  instead  of  being  obtunded, 
is  frequently  improved,  especially  when  anterior  hypertro- 
phies are  reduced  in  the  course  of  the  treatment.  This  is 
easily  explained  by  the  fact  that  the  olfactory  membrane 
is  not  involved  in  the  treatment,  and  that  by  facilitating 
the  passage  of  air  by  the  reduction  of  the  tumefactions, 
the  odoriferous  particles  can  reach  the  olfactory  area  in 
greater  number  and  with  more  freedom. 

The  permanent  nasal  hypera?sthesia  which  exists  in  the 
majority  of  hay  fever  cases,  through  which  irritating  sub- 
stances cause  much  annoyance,  itching,  sneezing  etc.,  is 
naturally  obviated  in  every  instance. 

As  to  the  permanency  of  the  immunity,  it  depends,  of 
course,  upon  the  thoroughness  with  which  the  treatment  is 
conducted.  A  spot  as  large  as  a  small  pea,  left  in  its 
hyperaesthetic  state  may  not  be  active  during  the  period 
of  the  first  paroxysm,  owing  to  the  proximity  of  the 
curative  treatment  and  the  temporary  local  inflammation 
set  up  by  it,  while  the  following  year,  having  reassumed 
its  hypera3sthesia,  it  may  occasion  unmistakable,  although 


PERIODICAL   HYPERJESTHETIC   RHINITIS.  201 

slight  symptoms  of  the  disease.  The  patient  should  there- 
fore be  requested  to  call  a  couple  of  weeks  before  the  usual 
date  of  the  onset,  in  order  that  any  hypera?sthetic  spot 
that  might  exist,  may  be  thoroughly  cauterized. 

Palliative  Treatment. — The  palliative  treatment  of  hay 
fever  may  be  conducted  either  during  the  attacks  or,  with 
a  view  to  prophylaxis,  during  the  interval  between  them. 
A  well  conducted  tonic  treatment,  begun  two  or  three 
months  before  the  onset  of  the  paroxysm,  sometimes  suc- 
ceeds in  markedly  diminishing  its  intensity,  nerve  tonics, 
such  as  nux  vomica,  arsenic  and  phosphorus,  being  espe- 
cially valuable.  When  anaemia  exists,  iron  should  be  given. 
Rabuteau's  pills  of  the  carbonate  of  iron  have  in  my 
hands  given  better  satisfaction  than  any  other  make,  not 
giving  rise  to  constipation  or  producing  other  deleterious 
effects.  Quinia,  six  grains  taken  daily  in  divided  doses,  is 
also  very  valuable  in  some  cases.  Morell  Mackenzie  recom- 
mends a  pill  of  valerianate  of  zinc,  one  grain,  and  compound 
assafcetida  pill,  two  grains,  beginning  some  time  before  the 
expected  attack,  arid  doubling  the  dose  at  the  end  of  ten 
days  or  two  weeks.  Out-door  exercise  is  an  important  ad- 
junct to  the  treatment,  while  vigorous  friction  with  a 
rough  towel  every  morning,  tends  greatly  to  invigorate 
the  system. 

When  the  patient  cannot  leave  for  some  location  in  which 
the  absence  of  the  irritant  or  irritants  which  affect  him 
insures  immunity,  high  altitudes,  the  sea  or  the  seashore,  a 
number  of  prophylactic  measures  may  be  taken  to  reduce 
the  violence  of  the  attack.  Of  these,  plugging  the  nostrils 
with  cotton  is  probably  the  most  effective,  the  irritant  be- 
ing thus  arrested  at  the  entrance  of  the  cavities,  and  not 
reaching  the  sensitive  areas.  Care  should  be  taken  not  to 
push  the  plug  too  far  in,  lest  the  contaminated  atmosphere 


202  DISEASES   OF   THE   ANTERIOR   NASAL    CAVITIES. 

pass  above  it.  It  should  be  introduced  just  within  the  nos- 
tril, and  so  adjusted  that  the  inhaled  air  be  forced  to  pass 
through  it.  In  some  cases,  even  that  does  not  prevent  the 
entrance  of  the  irritating  agent.  The  nostril  should  then  be 
hermetically  closed  with  cotton,  and  the  respiration  be  con- 
ducted through  the  mouth  for  the  time  being,  taking  care 
to  keep  the  lips  moist  and  as  near  together  as  possible,  in 
order  to  imitate  in  a  degree  the  functions  of  the  nasal  cav- 
ities. The  patient  should  as  much  as  possible  avoid  the 
sun,  the  reflex  irritation  of  the  nerve-centres  which  it  in- 
induces  through  the  eyes,  increasing  not  only  the  local 
symptoms,  but  also  those  of  the  respiratory  tract.  Large 
smoked  blue  spectacles  are  very  effective  for  this  purpose. 
Ladies  can  wear  thick  veils,  which  not  only  limit  the  access 
of  pollen  to  the  nose,  but  also  avoid  for  them  the  effect 
of  the  glare  of  the  sun  and  the  irritating  action  of  the 
wind  upon  the  skin  of  the  face. 

Medicinal  treatment  is  sometimes  of  benefit.  The  most 
effective  drug  at  our  disposal  is  cocaine,  which  is  capable  in 
some  cases,  of  subduing  a  paroxysm.  Applied  in  solution, 
however,  its  effect  is  slight,  its  strength  being  much  reduced 
by  the  unusual  amount  of  secretion  present.  Tablets  of 
cocaine,  gr.  |  each,  as  proposed  by  Dr.  Watson,  of  London, 
are  much  more  effective.  Being  introduced  into  the  nostrils, 
they  dissolve  in  the  mucus,  and  the  solution  formed  comes  in 
direct  contact  with  the  membrane. 

Ointments  are,  in  a  large  number  of  cases,  the  most  satisfac- 
tory agents  for  local  applications.  The  benzoated  oxide  of 
zinc  ointment  and  vaseline,  equal  parts,  not  only  soothes 
greatly  the  irritated  surfaces,  but  if  applied  frequently,  it 
seems  to  curtail  the  attack  by  limiting  the  access  of  the 
irritating  bodies  to  the  membrane.  It  should  be  applied  as 
thoroughly  as  possible  with  a  camel's  hair  pencil,  after 


PERIODICAL   HYPER^STHETIC   RHINITIS.  203 

having  liquefied  it  by  holding  the  vessel  containing  it  in  hot 
water.  Lennox  Browne,  of  London,  recommends  highly  an 
ointment  containing  a  drachm  of  oil  of  hamamelis  and  one 
ounce  of  vaseline.  Belladonna  ointment,  made  with  the 
aqueous  extract,  is  also  beneficial,  the  relief  being  further 
augmented  by  applying  it  over  the  nose  likewise.  The 
quinine  spray,  advocated  by  Helmholtz,  is  occasionally  bene- 
ficial. In  the  majority  of  cases,  however,  it  causes  irrita- 
tion, especially  when  used  cold.  One  grain  is  dissolved  in 
an  ounce  and  a  half  of  water  and  heated  to  100°  Fahr. 
A  spray  of  bicarbonate  of  soda  or  of  borax,  three  grains 
to  the  ounce,  used  at  the  same  temperature,  is  sometimes 
very  effective.  Inhalations  of  the  emanations  of  conium 
juice,  using  the  auto-insufflator  (Fig.  27),  in  which  a  cotton 
pledget  has  been  introduced,  is  also  beneficial  at  times, 
while  three  drops  each  of  liquid  carbolic  acid  and  the  oil 
of  tar,  used  in  the  same  manner,  sometimes  gives  much 
relief. 

For  the  eyes,  a  solution  of  two  drachms  of  spirits  of 
nitrous  ether  in  six  ounces  of  water,  used  with  a  coarse 
spray  atomizer  or  applied  with  compresses,  will  be  found 
useful.  A  two  per  cent,  solution  of  cocaine,  applied  with  a 
dropper,  is  very  effective  in  most  cases. 

Internal  remedies  are  sometimes  of  value.  The  elixir  of 
valerianate  of  ammonia,  a  teaspoonful  being  taken  every 
two  hours,  is  sometimes  surprisingly  effective.  Quinine, 
two  or  three  grains  three  times  a  day,  seems  also  to  exert 
a  beneficial  influence.  Morell  Mackenzie  recommends 
highly  the  pill  of  valerianate  of  zinc  or  assafoetida,  already 
alluded  to.  For  the  asthma,  a  preparation  containing  iodide 
of  potassium,  gr.  v,  tincture  of  belladonna,  HIV,  suspended 
in  syrup  of  orange  peel,  administered  every  two  hours  until 
the  symptom  ceases,  has  proven  exceedingly  efficient  in 


204  DISEASES   OF   THE   ANTERIOR   NASAL   CAVITIES. 

almost  every  ease  in  which  it  was  ordered.  The  inhalation 
of  the  fumes  of  nitrated  blotting  paper,  or  the  smoking  of 
stramonium  or  belladonna  cigarettes  is  also  advantageous 
in  some  cases.  The  depression  which  invariably  follows 
and  sometimes  precedes  an  attack  requires  the  moderate 
use  of  stimulants.  The  best  of  them,  in  my  opinion,  is 
wine  of  coca,  which,  theoretically,  is  admirably  adapted  to 
counteract  the  depressed  state  of  the  nerve-centres. 

ANOSMIA. 

Anosmia,  or  loss  of  the  sense  of  olf action,  occurs  as  a 
symptom  of  several  affections  of  the  nasal  cavity,  and  as  a 
result  of  lesions  of  the  olfactory  bulb  or  other  portions  of 
the  brain,,  of  idiopathic  or  traumatic  origin. 

Nasal  affections  may  give  rise  to  anosmia  by  interfering 
mechanically  with  the  access  of  the  odoriferous  bodies  to 
the  olfactory  nerves,  or  by  annulling  their  sensitiveness 
through  extension  of  the  inflammatory  process  to  the  olfac- 
tory area.  Acute  rhinitis,  hypertrophic  rhinitis,  and  nasal 
polypi  can  thus  cause  anosmia  by  the  obstruction  to  which 
they  give  rise,  while  simple  chronic  and  syphilitic  rhinitis 
may  act  as  exciting  causes  by  involving  the  mucous  mem- 
brane of  the  olfactory  area  in  the  local  inflammation. 
Atrophic  rhinitis  may  also  give  rise  to  it,  the  impaired  or 
arrested  action  of  the  lubricating  glands  failing  to  furnish 
the  fluids  necessary  to  dissolve  the  odoriferous  particles 
over  the  olfactory  nerves. 

Lesions  of  the  olfactory  bulb  are  in  most  cases  due  to  a 
blow  received  either  over  the  supra-orbital  region  or  upon 
any  other  portion  of  the  head.  Its  soft  consistence  causes 
it  to  become  easily  disorganized,  and  once  broken  up,  it 
does  not  recover.  Central  brain  lesions,  tumors,  abscesses, 
etc.,  are  occasionally  accompanied  by  loss  of  smell.  The 


ANOSMIA.  205 

other  symptoms  of  the  case  serve  to  clear  the  diagnosis. 
The  olfactory  bulb  or  its  branches  may  be  imperfectly  de- 
veloped or  absent.  The  continued  inhalation  of  strong 
odors,  or  tobacco  smoke,  by  over-stimulating  the  olfac- 
tory nerves,  also  causes  anosmia.  This  over-stimulation 
may  also  be  brought  about  by  the  prolonged  use  of  to- 
bacco or  other  irritating  snuffs.  Certain  drugs,  such  as 
morphia,  alum,  tannin,  etc.,  when  used  to  excess  have 
been  known  to  impair  and  even  destroy  the  sense  of  smell. 
The  sense  of  taste,  owing  to  its  close  relationship  with  the 
latter,  is  impaired  in  the  majority  of  the  cases  of  anosmia. 
Treatment. — When  anosmia  is  due  to  an  acute  affection, 
the  sense  of  smell  usually  returns  when  the  latter  disap- 
pears. In  chronic  conditions,  the  treatment  applied  for 
their  relief  is  obviously  that  indicated  for  the  anosmia, 
and  it  will  meet  with  success  if  the  integrity  of  the  twigs 
of  the  olfactory  nerve  is  not  too  greatly  compromised. 
When  olfaction  has  been  absent  for  a  number  of  years, 
the  chances  of  recovery  are  very  meagre,  while  in  cases 
caused  by  blows  or  falls,  a  cure  is  not  to  be  expected. 
When  the  condition  acting  as  primary  cause  has  been  treated 
and  the  anosmia  still  persists,  strychnine  used  locally  is 
sometimes  very  efficient,  combined  with  the  application  of 
the  faradic  current.  The  former  may  be  administered  as  a 
snuff,  one-fortieth  of  a  grain  being  thoroughly  triturated 
in  two  grains  of  sugar  and  used  with  the  auto-insufflator 
(Fig.  27)  night  and  morning.  Care  should  be  taken  to  in- 
troduce the  tip  of  the  instrument  as  far  as  possible,  directing 
it  towards  the  roof  of  the  nose.  The  faradic  current  should 
be  used  every  day,  a  moderate  current  being  passed  from 
the  inter-orbital  space  to  the  occiput,  the  negative  pole 
being  placed  over  the  former.  Thoroughly  wetting  the 
sponges  will  insure  penetration  of  the  current,  which  would 
otherwise  pass  around  the  head. 


CHAPTER   XI. 

DISEASES   OF   THE   ANTERIOR   NASAL   CAVITIES. — (Continued.) 

EPISTAXIS. 

(Synonyms:  —  Nose-bleed;    Hemorrhagia  Narium  ;    Rhinorrhagia.) 

Etiology. — Bleeding  at  the  nose  may  be  due  to  trauuia- 
tism,  such  as  blows,  falls,  picking  with  the  finger-nails,  the 
introduction  of  a  foreign  body,  forcibly  blowing  the  nose, 
sneezing,  etc.  It  is  a  frequent  symptom  of  the  majority  of 
nasal  tumors,  and  of  the  forms  of  rhinitis  accompanied  by 
ulceration.  It  occasionally  occurs  as  a  vicarious  substitute 
for  menstruation.  An  obstruction  to  the  general  circulation 
or  any  condition  increasing  the  tension  of  the  blood-vessels, 
may  give  rise  to  it,  while  a  weakened  state  of  the  vessel 
walls,  which  may  be  local  through  prolonged  catarrhal  in- 
flammation, or  general,  through  degeneration  of  the  vessels  at 
large  as  a  result  of  disease  or  old  age,  may  act  as  a  primary 
cause.  It  may  also  be  the  result  of  obstruction  to  the  return 
of  blood  to  the  heart  through  pressure  upon  the  jugular 
veins  by  tumors,  closely-fitting  neck-wear,  etc.  A  constitu- 
tional susceptibility  to  hemorrhages  exists  in  some  individ- 
uals, the  bleeding  being  at  the  nose  in  the  majority  of  cases ; 
in  these,  the  liability  to  epistaxis  may  be  congenital. 

Epistaxis  occurs  as  a  premonitory  or  concomitant  symp- 
tom in  a  number  of  affections,  such  as  typhoid  and  remit- 
tent fevers,  scurvy,  diphtheria,  and  the  exanthemata.  In 
plethora  and  when  the  cerebral  circulation  is  overloaded,  a 
free  nose-bleed  is  generally  productive  of  great  relief. 

Pathology. — The  profuseness  with  which  the  nasal  mucous 
membrane  is  supplied  with  blood-vessels,  furnishes  a  ready 
explanation  for  the  copious  hemorrhages  which  occur  as  a 
(206) 


EPISTAXIS.  207 

result  of  traumatism.  A  blow,  by  suddenly  increasing  the 
blood-pressure  readily  causes  rupture  of  one  or  several  blood- 
vessels. The  fact  that  arterial  blood  is  generally  lost  indi- 
cates that  the  venous  sinuses  are  but  seldom  involved. 
Picking  the  nose,  by  denuding  the  membrane  of  its  epi- 
thelium, exposes  the  underlying  membrane  proper,  tearing 
some  of  the  numerous  blood-vessels.  The  hemorrhage  some- 
times originates  in  the  posterior  nasal  cavity,  especially  in 
the  mass  of  glandular  tissue  with  which  the  vault  is 
furnished. 

Symptoms. — In  epistaxis  due  to  traumatism,  the  blood 
flows  freely  in  most  cases  from  one  side.  These  hemor- 
rhages usually  cease  of  their  own  accord,  and  are  not  of 
long  duration.  In  most  of  the  other  forms  of  epistaxis, 
the  blood  trickles  by  drops,  which  follow  each  other  in 
more  or  less  rapid  succession.  In  nose-bleed  occurring  as 
a  result  of  cerebral  congestion,  premonitory  symptoms,  such 
as  headache,  tinnitus  aurium,  injection  of  the  conjunctiva, 
etc.,  are  usually  experienced,  which  are  much  improved  or 
disappear  altogether  as  soon  as  a  certain  amount  of  blood 
has  been  lost.  In  individuals  subject  to  hemaphilia,  the 
attacks  may  occur  at  any  time,  the  least  exertion  serving 
sometimes  to  bring  on  a  severe  epistaxis.  When  the  con- 
dition is  due  to  vicarious  menstruation,  it  usually  presents 
itself  about  the  time  the  latter  should  begin,  with  inter- 
mittent recurrences  during  the  usual  duration  of  the  men- 
strual flow.  In  general  softening  of  the  vessel  walls,  nose- 
bleed usually  begins  after  an  exertion,  and  is  exceedingly 
difficult  to  arrest.  When  the  bleeding  originates  in  the 
vault  of  the  pharynx,  the  blood  flows  posteriorly  when  the 
patient  is  sitting  up  or  standing. 

Prognosis. — In  almost  every  case,  epistaxis  is  not  followed 
by  serious  results.  The  lost  blood  is  soon  reformed,  and 


208  DISEASES   OF   THE   ANTERIOR   NASAL   CAVITIES. 

prompt  recuperation  of  lost  forces  takes  place.  When  oc- 
curring in  persons  of  great  debility  it  may  cause  death  by 
exhaustion. 

Treatment. — The  position  of  the  body  bears  great  influence 
upon  the  violence  and  duration  of  an  attack  of  nose-bleed. 
In  a  case  seen  in  consultation,  the  epistaxis,  although  not 
profuse,  had  already  lasted  upwards  of  twelve  hours,  the 
patient  having  remained  in  the  recumbent  position,  with 
his  head  hanging  over  a  pail,  throughout  the  entire  time. 
The  mere  return  to  the  upright  position  caused  the  flow 
to  cease  at  once.  When  there  is  great  tendency  to  coma, 
however,  the  sitting  posture  should  be  tried,  and  if  this 
cannot  be  endured,  lying  flat  on  the  back  is  the  next  best 
position. 

The  hemorrhage  can  frequently  be  arrested  by  simply 
closing  tightly  the  bleeding  nostril  for  a  few  minutes,  es- 
pecially when  the  flow  arises  from  the  anterior  portion  of 
the  septum.  Pressure  upon  the  artery  of  the  septum  as  it 
enters  the  nostril,  or  upon  the  branch  of  the  facial,  situated 
close  to  the  ala?,  will  sometimes  suffice.  Raising  the  arms 
above  the  head  to  force  the  blood  to  mount  against  gravity, 
thus  encouraging  the  formation  of  a  clot,  is  also  recom- 
mended. Derivative  treatment,  such  as  hot  foot-baths,  mus- 
tard plasters  to  the  back  of  the  neck,  ankles,  or  chest,  may 
also  be  employed,  while  stimulation  of  the  vaso-motors  can 
be  induced  by  the  application  of  cold  in  the  form  of  ice, 
cold  compresses,  ice  bags  over  the  nose,  forehead,  nucha,  etc. 

When  these  simple  means  fail,  the  local  application  of 
styptics  may  be  employed.  Sniffling  ice-water,  into  which 
a  little  salt  has  been  dissolved,  is  sometimes  very  effective. 
Insufflations  of  tannic  acid,  gallic  acid,  or  alum,  either  sepa- 
rate or  combined,  by  means  of  the  auto-insufflator  (Fig.  27), 
or  posteriorly  with  the  scoop  insufflator  (Fig.  25),  will  arrest 


EPISTAXIS,  209 

the  bleeding  in  most  of  the  severe  cases.  The  styptic 
preparations  of  iron  are  preferred  by  some,  but  I  have  not 
found  them  more  effective  than  the  above,  while  their  use 
is  much  more  unpleasant  to  both  patient  and  physician. 
Solutions  of  sulphate  of  zinc,  acetate  of  lead,  or  sulphate  of 
copper  (gr.  xxx-3J)  may  be  applied  with  a  syringe  or  with 
the  atomizer.  In  connection  with  the  treatment,  blowing 
of  the  nose  should  be  avoided  for  some  time,  so  as  not 
to  remove  the  clots  which  arrest  the  bleeding  mechanically. 
When  evidences  of  weakness  become  apparent,  such  as 
pallor,  vertigo,  etc.,  mechanical  means  must  be  resorted  to. 
The  simplest  of  these  is  to  pack  the  bleeding  cavity  with 
pledgets  of  cotton,  lint,  or  bits  of  sponge,  previously  dipped 

Fig.  56. 


Bellocq's  canula  when  not  in  use. 

in  some  styptic  solution,  and  of  sufficient,  size  to  exert 
pressure  when  in  place.  Any  blunt  instrument  may  be 
used  to  mass  them  in,  one  after  the  other.  They  can  be 
withdrawn  with  dressing  forceps  after  twenty-four  hours, 
and  new  ones  replaced  if  necessary.  Dr.  R.  J.  Levis,  of 
this  city,  uses  small  pieces  of  sponge  passed  successively 
over  a  piece  of  twine. 

In  some  cases,  the  point  of  origin  of  the  hemorrhage 
is  so  far  back  that  anterior  packing  is  not  sufficient.  Re- 
sort must  be  had  to  posterior  tamponing,  a  rather  difficult 
procedure  in  most  cases.  Bellocq's  canula,  an  instrument 
especially  adapted  for  the  purpose,  may  be  used.  It  con- 

14 


210  DISEASES   OF   THE   ANTEKIOB,  NASAL   CAVITIES. 

sists  of  a  metallic  tube  through  which  a  curved  steel  spring 
moves  freely.  When  the  instrument  is  passed  through  the 
bleeding  nostril,  the  curved  spring  is  forced  out  by  a  movable 
rod  connected  with  it,  and  its  shape  causes  it  to  curl  into 
the  mouth,  presenting  a  perforated  knob,  to  which  a  string 
furnished  with  a  cotton  tampon  the  size  of  the  patient's 
thumb,  is  attached.  The  instrument  being  drawn  out,  the 
tampon  is  pulled  up  behind  the  soft  palate,  and  into  the 
narium,  which  it  closes  up  tightly.  This  procedure  is  very 
effective  when  the  nasal  cavity  is  sufficiently  well  formed  and 
wide  enough  to  allow  the  introduction  of  the  canula.  In  the 

Fig.  57- 


Bellocq's  canula  when  in  position. 

majority  of  cases,  however,  great  trouble  is  experienced  in 
introducing  it,  and  in  some  cases,  through  marked  devia- 
tion of  the  septum,  the  presence  of  hypertrophies,  etc.,  the 
manipulation  cannot  be  accomplished.  A  more  univer- 
sally successful  procedure  is  to  use  a  small  flexible  rubber 
bougie ;  when  pressed  into  the  nostril,  it  accommodates 
itself  to  the  irregularities  of  the  respiratory  tract  and  finally 
emerges  into  the  naso-phaiynx,  the  wall  of  which  causes 
the  tip  to  turn  downward  and  protrude  below  the  soft 
palate,  when  it  can  be  seen  through  the  mouth  and  drawn 
out  with  a  pair  of  forceps.  A  string  furnished  with  a 
tampon  being  attached  to  it,  when  the  bougie  is  drawn 


EPISTAXIS.  211 

out,  the  tampon  is  drawn  into  place.  The  string  should 
always  be  double  so  that  one  end  will  protrude  through 
the  nose  and  the  other  through  the  mouth,  the  two  being 
tied  over  the  upper  lip  to  retain  the  tampon  in  place. 
Much  trouble  is  sometimes  experienced  in  passing  the  latter 
behind  the  soft  palate,  which  will  adapt  itself  against  the 
pharynx  and  prevent  its  introduction.  This  can  be  avoided 
by  passing  the  index  finger  through  the  isthmus  and  leav- 
ing it  there  until  the  tampon  has  passed  into  the  pharyn- 
geal  vault.  If  left  in  place  too  long,  tampons  may  cause 
systemic  poisoning  and  tetanus;  they  should  therefore  be 
changed  after  twenty-four  hours,  or  at  most  forty-eight. 

FOREIGN   BODIES   IN  THE  NASAL  PASSAGES. 

Children  frequently  insert  foreign  bodies,  such  as  but- 
tons, pebbles,  cherry  stones,  beans,  hairpins,  etc.,  in  their 
nasal  passages,  where  they  may  remain  impacted  for  a  num- 
ber of  years.  Insane  people  do  likewise  occasionally.  In 
adults,  foreign  bodies  are  very  rarely  met  with  in  the  nasal 
passages,  their  introduction  being  generally  due  to  acci- 
dental causes.  Necrosed  bones,  when  detached,  become 
foreign  bodies,  and  give  rise  to  all  the  symptoms  charac- 
terizing their  presence.  In  a  few  rare  cases  the  foreign 
bodies  are  ascarides  or  other  human  parasites,  which  are 
either  forced  up  into  the  posterior  nasal  cavity  by  coughing 
or  crawl  up  along  the  pharynx. 

Symptoms. — At  first  the  presence  of  a  foreign  body  attracts 
but  little  attention.  The  timid  child  refrains  from  men- 
tioning his  mischievous  act,  and  soon  forgets  it.  After 
some  time,  a  discharge  of  glairy  mucus  begins;  this  soon 
becomes  purulent,  and,  if  the  foreign  body  presents  asperi- 
ties, may  be  tinged  with  blood.  In  some  cases  the  dis- 
charge becomes  extremely  fetid.  Round  bodies,  if  small, 


212  DISEASES   OF   THE   ANTERIOR   NASAL   CAVITIES. 

cause  a  hardly  perceptible  discharge,  which,  nevertheless, 
is  sufficient  to  excoriate  the  nostril.  Beans,  peas,  and 
other  vegetable  substances,  absorb  the  watery  constituents 
of  the  secretion,  swell  considerably,  and  occasionally  germ- 
inate, increasing  greatly  the  intensity  of  the  symptoms. 
When  the  bodies  are  large  or  hard,  such  as  bullets,  large 
pebbles,  etc.,  they  may  occasion  considerable  pain  of  a  neu- 
ralgic character,  headache,  etc.  Obstruction  to  nasal  respi- 
ration is  of  course  proportionate  with  the  size  of  the  for- 
eign body. 

Treatment. — The  extraction  of  a  foreign  body  from  the 
nasal  passages  is  at  times  exceedingly  difficult,  especially 
when  it  has  been  in  the  cavity  for  a  prolonged  period, 
during  which  it  sometimes  becomes  covered  with  a  calca- 


Gross'  ear  curette. 


reous  coat.  It  is  generally  deeply  imbedded  in  the  mucous 
membrane,  and  occasionally  surrounded  by  fungous  growths. 
In  ordinary  cases,  forcible  sneezing,  induced  by  tickling 
the  inside  of  the  nose,  may  be  tried.  If  unsuccessful,  the 
posterior  douche  may  be  more  successful,  used  by  raising 
the  can  above  the  head  so  as  to  obtain  a  powerful  stream. 
Hall's  syringe  (Fig.  16)  will  be  found  very  convenient,  the 
force  of  the  current  being  easily  regulated.  These  failing, 
surgical  means  must  be  resorted  to.  In  the  majority  of  cases, 
such  an  instrument  as  Gross'  ear  curette  (Fig.  58)  may  be 
used,  the  spoon-like  tip  giving  the  operator  good  purchase. 
Another  convenient  instrument  is  that  shown  in  Fig.  59. 
A  pair  of  delicate  forceps  may  be  more  efficient  in  some 
cases.  In  these  manipulations,  however,  care  should  be 
taken  not  to  lacerate  the  membrane,  and  to  avoid  pushing 


RHINOLITHS.  213 

the  foreign  body  still  deeper  in  the  fossa.  "When  the  for- 
eign body  is  deep-seated,  a  method  which  I  have  found 
effective  is  to  pass  a  piece  of  slender  wire  along  the  floor 
of  the  nose  as  far  back  as  the  pharynx,  withdrawing  the 
end  out  of  the  mouth  with  forceps,  A  tampon  of  cotton 
or  linen  being  securely  attached  to  it,  and  drawn  up  be- 
hind the  palate  into  the  posterior  nares,  it  is  pulled 
through  the  nasal  cavity  along  with  the  foreign  body.  In 
a  case  in  which  a  pebble  could  not  be  grasped,  I  passed 
two  wires,  one  above  and  one  under  it,  into  the  mouth, 
then  tied  a  long  piece  of  strong  tape  between  the  two 
ends,  thus  forming  a  loop  with  which  the  foreign  body 
was  withdrawn  as  a  cork  is  pulled  out  of  the  body  of  a 
bottle. 

Fig.  59- 


Bent  tip  curette.     (Inventor's  name  could  not  be  ascertained.) 
RHINOLITHS. 

Khinoliths  are  calcareous  concretions,  varying  in  size 
from  a  millet-seed  to  an  almond,  formed  by  the  accumula- 
tion of  the  alkaline  constituents  of  the  secretions  (princi- 
pally phosphate  of  lime)  around  a  foreign  body  in  the  nasal 
passages.  They  sometimes  originate  from  a  small  mass  of 
desiccated  mucus.  A  gouty  diathesis  is  thought  by  Graefe 
to  be  favorable  to  their  formation. 

Symptoms. — The  symptoms  occasioned  by  the  presence  of 
rhinoliths  resemble  those  of  a  foreign  body.  At  first,  how- 
ever, its  presence  is  hardly  noticed,  its  effects  becoming  per- 
ceptible when  it  has  attained  a  sufficient  size.  A  nasal  dis- 
charge, which  gradually  thickens,  presents  itself,  and,  as  the 
inflammation  of  the  surrounding  mucous  membrane  becomes 
more  and  more  marked,  obstruction  to  nasal  respiration 


214  DISEASES   OF   THE   ANTEIUOE   NASAL   CAVITIES. 

takes  place  with  its  accompanying  symptoms,  nasal  voice, 
anosmia,  etc.  Headache  is  a  frequent  symptom  when  the 
calculus  is  large.  What  part  of  a  rhinolith  presents  itself, 
generally  appears  black ;  it  can  thus  be  mistaken  for  a 
necrosed  bone,  being  partially  buried,  like  the  latter,  in  the 
mucous  membrane.  Its  gritty  surface  may  also  cause  con- 
fusion with  dead  bone,  but  the  horrible  odor  emanating  from 
the  latter  is  of  course  absent. 

Treatment. — An  ordinary  dressing  forceps  generally  suffices 
to  dislodge  a  rhinolith,  but  at  times  the  mucous  membrane 
surrounding  it  has  to  be  first  detached,  an  operation  readily 
done  with  Professor  Gross'  curette,  the  spoon-shaped  end 
being  pushed  between  the  stone  and  the  membrane.  When 
it  is  very  large,  a  diminutive  lithotrite  has  to  be  used  to 
crush  it  and  extract  it  piecemeal. 

MAGGOTS   IN  THE  NOSE. 

The  fetid  odor  accompanying  certain  catarrhal  affections 
of  the  nose,  occasionally  attracts  flies  and  other  insects. 
When  these  penetrate  the  nasal  cavity  and  deposit  eggs 
within  them,  maggots  are  hatched,  this  process  being 
assisted  by  the  heat  of  the  surrounding  surfaces.  The 
mucous  membrane  is  destroyed  by  them,  and  the  cartilage 
and  bones  become  necrosed.  This  condition,  however,  is 
seldom  met  with  in  this  country,  occurring  principally  in 
India  and  in  Central  and  South  America. 

Symptoms. — Itching  in  the  nose  is  the  first  symptom.  For- 
mication and  a  gnawing  sensation  are  then  experienced, 
both  increasing  markedly.  Occasional  hemorrhages  occur, 
accompanied  by  a  profuse  muco-purulent  discharge.  Great 
cephalagia  is  usually  complained  of.  Convulsions  and  coma 
occur  in  fatal  cases. 

Treatment. — Inhalations    of    chloroform,    as    proposed    by 


MAGGOTS   IN  THE    NOSE.  215 

Dauzat,  are  fatal  to  the  maggots,  and  their  destruction  is 
the  cure  of  the  affection.  Pure  chloroform  may  be  injected 
into  the  cavities  when  inhalations  are  not  effective,  a  pro- 
cedure harmless  to  the  membrane. 


CHAPTER  XII. 

DISEASES   OF   THE   POSTEEIOE   NASAL    CAVITY. 
ACUTE  POSTERIOR  NASAL  PHARYNGITIS. 

(Synonyms:  —  Acute    Catarrh    of    the    Naso-Pharynx ;    Acute    Retro- 
Nasal    Catarrh ;  Acute    Post-Nasal    Catarrh.) 

Etiology. — Acute  inflammation  of  the  posterior  nasal  cavity 
may  occur  primarily  as  a  concomitant  symptom  of  acute 
rhinitis  and  be  due  to  the  same  causes,  but  it  most  fre- 
quently presents  itself  as  a  complication  of  that  affection 
and  of  acute  pharyngitis.  It  is  sometimes  caused  by  the 
inhalation  of  dust  or  other  irritating  particles,  through  me- 
chanical action,  and  is  a  frequent  accompaniment  of  a 
number  of  diseases  of  childhood,  such  as  diphtheria,  measles, 
scarlatina,  etc.  A  scrofulous  diathesis  seems  to  predispose 
to  it.  The  irregular  climate  of  this  country  renders  it  of 
frequent  occurrence,  and,  although  its  symptoms  are  seldom 
of  sufficient  intensity  to  require  medical  aid,  it  assumes 
great  importance  as  the  precursory  stage  of  the  so-called 
post-nasal  catarrh. 

Pathology. — Hypei^emia  of  the  glandular  tissue  may  take 
place  as  a  result  of  peripheral  irritation,  as  by  cold,  etc., 
the  impression  being  transmitted  through  the  sympathetic 
system,  and  causing  a  sudden  contraction  of  the  local  blood- 
vessels soon  followed  by  dilatation  and  engorgement,  but  I 
doubt  whether  in  the  naso-pharynx  this  occurs  as  uni- 
versally as  it  does  in  the  anterior  nasal  cavities,  in  which 
the  vascular  supply  is  very  great,  with  a  correspondingly 
important  vaso-motor  innervation.  I  am  more  inclined  to 
(216) 


ACUTE   POSTEEIOE  NASAL  PHARYNGITIS3  217 

consider  inflammation  here  as  due,  in  the  majority  of  eases, 
to  contiguity  of  tissue,  and  as  a  complication  of  an  inflam- 
matory process  in  a  neighboring  part. 

In  some  individuals,  especially  those  of  a  scrofulous  tem- 
perament, a  preternatural  sensitiveness  of  the  naso-pharynx 
causes  it  to  become  easily  influenced  by  conditions  which 
would  in  others  bring  on  acute  rhinitis,  and  a  localized 
hypersemia  is  engendered  which  either  disappears  or  forms 
the  initial  step  to  further  pathological  changes. 

Symptoms. — When  the  affection  occurs  as  a  complication 
of  acute  rhinitis,  the  symptoms  of  the  latter,  as  regards 
obstruction  to  breathing  and  copious  secretion,  are  so 
marked,  that  those  occurring  in  the  posterior  cavity  are 
generally  overlooked.  When  the  latter  is  solely  affected, 
however,  as  is  frequently  the  case  in  scrofulous  subjects, 
the  first  symptom  is  a  sensation  of  dryness  or  parchedness 
behind  the  soft  palate,  accompanied  by  a  feeling  of  con- 
striction, especially  marked  during  deglutition,  which  some- 
times becomes  painful.  A  thick,  starch-like  secretion  soon 
begins,  and  after  a  couple  of  days  this  becomes  still  thicker, 
assuming  at  the  same  time  a  purulent  character.  The  dis- 
charges are  hawked  into  the  mouth  or  swallowed.  The 
voice  becomes  shallow  or  thick,  and  sometimes  quite  nasal. 
Pain  at  the  top  of  the  head  is  frequently  complained  of. 
Hearing  is  sometimes  compromised  through  participation, 
in  the  inflammatory  process,  of  the  mucous  lining  of  the 
Eustachian  tubes.  These  symptoms  are  generally  well 
marked  in  affections  such  as  diphtheria,  scarlatina,  etc., 
of  which  it  is  a  frequent  accompaniment.  When  the  inflam- 
mation is  marked,  bleeding  often  occurs. 

Examined  rhinoscopically,  the  parts  appear  congested  and 
somewhat  thickened,  and  masses  of  the  discharge  described 
are  seen  clinging  to  the  dem*essions  and  crypts  of  the  lining 
membrane. 


218  DISEASES   OF   THE   POSTERIOR   NASAL   CAVITY. 

Prognosis. — Acute  inflammation  of  the  posterior  nasal 
cavity  may  rapidly  disappear,  but  in  the  majority  of  cases, 
it  is  the  primary  manifestation  of  the  chronic  condition. 

Treatment. — As  is  the  case  with  acute  rhinitis,  cases  of 
this  character  seldom  apply  for  treatment.  When  inflam- 
mation of  the  anterior  and  posterior  cavities  occur  simul- 
taneously, the  treatment  of  the  former  suffices  for  both 
conditions,  the  one  following  the  course  of  the  other.  When 
the  posterior  cavity  is  alone  involved,  however,  the  remedies 
are  best  applied  directly  to  the  parts  by  means  of  the  in- 
sufflator devised  by  Dr.  A.  H.  Smith,  Fig.  26,  or  that  shown 
in  Fig.  61. 

The  powder  recommended  on  page  69  will  be  found  very 
effective  when  the  case  is  seen  early,  the  local  hypersemia 
being  influenced  in  the  same  manner  as  in  acute  rhinitis. 
When  the  parts  appear  dry  and  parched,  as  they  do  at 
the  very  start  of  the  trouble,  a  solution  of  bicarbonate  of 
sodium  (gr.  v-lj)  will  be  very  grateful  to  the  patient,  and 
in  some  cases  arrest  the  attack  at  once.  An  atomizer  with 
a  curved  tip  must  be  used  for  the  purpose,  such  as  that  in 
Fig.  60.  A  solution  of  sulphate  of  sulpho-carbolate  of  zinc 
(gr.  v-lj)  is  also  very  effective  when  the  secretion  is  pro- 
fuse, by  causing  contraction  of  the  superficial  blood-vessels 
and  the  glandule.  A  four  per  cent,  solution  of  cocaine  is 
doubtless  as  effective  here  as  in  acute  rhinitis,  especially 
when  there  is  pain. 

CHRONIC   POSTERIOR   NASAL   PHARYNGITIS. 

(Synonyms: — Chronic  Catarrh  of  the  Naso-Pharynx ;  Follicular  Dis- 
ease of  the  Naso-Pharyngeal  Space ;  Post-Nasal  Catarrh ;  Retro- 
Nasal-Catarrh.) 

The  almost  universal  prevalence  of  post-nasal  catarrh  in 
this  country  has  given  rise  to  much  speculation  among 


CHRONIC   POSTERIOR  NASAL   PHARYNGITIS.  219 

specialists,  and  many  are  the  views  advanced  as  to  its 
etiology.  The  scope  of  this  work  not  permitting  their  enu- 
meration, I  will  but  state  those  which  I  have  personally 
entertained  for  some  time,  and  which  close  observation  and 
satisfactory  results  in  a  large  number  of  cases,  have  led  me 
to  consider  as  the  true  one. 

Etiology. — Chronic  inflammation  of  the  nasopharynx  may 
be  due,  firstly,  to  repeated  attacks  of  acute  posterior  nasal 
pharyngitis  occurring  independently  or  simultaneously  with 
acute  inflammatory  affections  of  the  anterior  nasal  cavities ; 
secondly,  to  chronic  inflammatory  processes  in  the  neigh- 
boring parts,  the  anterior  nasal  cavities  or  the  pharynx ; 
thirdly,  to  the  presence  in  the  anterior  nasal  cavities  of 
turgescences,  hypertrophies,  polypi  and  other  growths  and 
septal  deviations,  and  all  conditions  which  interfere  me- 
chanically with  the  performance  of  the  physiological  func- 
tions of  the  nose  and  with  the  anterior  flow  of  discharges; 
fourthly,  to  a  scrofulous  diathesis,  or  a  pseudo-scrofulous 
state  of  the  system  occurring  as  a  result  of  a  number  of 
diseases,  among  which  scarlatina,  diphtheria,  measles  and 
smallpox  are  the  principal. 

Pathology. — A  fact  of  great  importance  in  connection  with 
the  pathological  consideration  of  this  affection,  is  the  slow- 
ness with  which  glandular  tissue  enters  resolution  after 
having  undergone  an  inflammatory  process,  as  compared 
with  other  tissues.  An  acute  inflammation  of  either  the 
anterior  nasal  cavities  or  the  pharynx  having  implicated 
the  naso-pharynx,  the  profuseness  of  glandular  elements  in 
the  latter  cause  it  to  retain,  as  it  were,  the  inflammatory 
process  much  longer  than  the  parts  primarily  inflamed.  If 
the  anterior  cavities  undergo  a  renewed  attack  before  the 
naso-pharynx  has  fully  recuperated  from  the  preceding,  the 
congestion  of  the  glandular  tissue  is  increased  in  proportion, 


220  DISEASES   OF   THE   TOSTERIOK   NASAL   CAVITY. 

and  the  chances  of  entire  resolution  are  diminished.  Re- 
newed attacks  decrease  these  chances  more  and  more,  until 
chronicity  is  established.  This,  it  seems  to  me,  is  the  course 
of  events  in  the  majority  of  cases  of  post-nasal  catarrh  in 
this  country.  The  irregular  climate  and  other  causes,  most 
of  which  have  been  enumerated  in  the  chapter  on  the  dif- 
ferent forms  of  rhinitis,  cause  frequent  attacks  of  acute 
rhinitis,  and  a  few  succeeding  attacks  are  sufficient  in  most 
individuals  to  establish  a  chronic  post-nasal  inflammatory 
process. 

In  the  second  category  of  the  causes  enumerated,  the 
process  is  the  same,  the  post-nasal  affection  being  merely 
a  part  of  the  general  trouble. 

In  the  third  category,  the  chronic  inflammation  induced 
by  the  presence  of  hypertrophies,  growths,  etc.,  is  in  itself 
sufficient  to  cause  by  continuity  of  tissue,  a  catarrhal  state 
of  the  naso-pharynx,  this  being  further  aggravated  by  the 
constant  passage  over  it  of  more  or  less  irritating  dis- 
charges, which  cannot,  through  the  mechanical  interference 
offered  by  the  abnormal  formations,  be  freely  evacuated 
anteriorly. 

In  the  fourth,  the  proclivity  to  inflammation  peculiar  to 
the  scrofulous  diathesis  is  the  starting  point  of  the  trouble, 
while  the  recuperative  powers  are  not  sufficiently  strong  to 
cause  resolution. 

Symptoms. — In  mild  cases  of  post-nasal  catarrh,  the  prin- 
cipal symptom  generally  complained  of,  is  an  increased  dis- 
charge of  mucus,  a  "dropping,"  as  the  patients  term  it,  of 
starch-like,  gluey  lumps  of  thickened  mucus,  which  adhere 
tenaciously  to  the  surface  upon  which  they  are  expecto- 
rated, after  having  been  "hawked"  into  the  mouth.  This 
may  occur  several  times,  or  only  once  daily,  or  less  often. 
During  the  presence  of  the  mass  in  the  naso-pharynx,  a 


CHEONIC  POSTERIOR  NASAL   PHARYNGITIS.  221 

feeling  of  fullness  is  experienced,  the  voice  may  be  muffled 
or  deadened,  and  acquire  the  nasal  twang.  After  a  year 
or  more  of  this  condition,  the  discharges  begin  to  assume 
a  purulent  character,  oyster-like,  muco-purulent  lumps 
taking  the  place  of  those  described.  These  are  occasionally 
streaked  with  blood,  or  present  a  brownish  appearance 
which  betokens  its  presence.  Instead  of  being  inodorous 
as  before,  these  discharges  may  assume  a  somewhat  offen- 
sive odor,  especially  if  they  have  remained  for  any  length 
of  time  pent  up  in  the  cavity.  The  hawking  necessary  to 
dislodge  them,  is  much  more  frequently  resorted  to,  and 
habit  being  added  to  necessity,  the  patient  is  greatly  an- 
noyed and  becomes  a  disagreeable  companion.  This  is  fur- 
ther aggravated,  in  some  cases,  by  the  extension  of  the  in- 
flammatory process  to  the  lower  pharynx  and  the  larynx, 
which  renders  an  occasional  "hemming"  a  source  of  mo- 
mentary relief  for  the  patient.  Dull  pain  on  the  top  of  the 
head  is  often  complained  of,  while  frontal  headache  is  also 
present  if  the  anterior  cavities  are  affected.  In  some  cases 
the  memory  seems  to  be  dulled.  The  mouths  of  the  Eusta- 
chian  tubes  are  sometimes  implicated,  and  the  hearing  may 
become  compromised.  In  aggravated  cases,  the  discharges 
assume  a  decidedly  purulent  character,  forming  hard,  con- 
crete scabs,  which  emit  a  fetid  odor,  and  frequently  present 
the  shape  of  the  surfaces  from  which  they  became  detached. 
The  efforts  of  the  patient  to  discharge  these  masses,  which 
have  become  almost  dry  by  evaporation  of  their  watery  con- 
stituents, by  hacking,  coughing,  scraping,  etc.,  now  become 
more  frequent.  This  maintains  the  soft  palate  in  a  con- 
gested condition,  and  after  a  time  its  volume  becomes  in- 
creased, causing  drooping,  and  the  symptoms  of  elongated 
uvula  are  added  to  the  others,  a  coated  tongue,  general 
congestion  of  throat,  nausea,  a  hacking  cough,  etc.,  wrhile 


222  DISEASES    OF   THE   POSTERIOR   NASAL   CAVITY. 

dyspepsia  may  bo  engendered  by  occasional,  unavoidable 
swallowing  of  the  discharges.  Patients  of  this  kind  gen- 
erally present  an  anaemic  appearance. 

Examination    of    the   parts   by  means   of    the    rhinoscope 
generally  reveal  the  presence   of  masses   of  secretion   of  a 
color  and  character  varying  with  the  stage  of  the  affection, 
and  adhering  tenaciously  to  the  walls  of  the  cavity.     These 
being  eliminated  by  means  of  the  atomizer  or  Hall's  syringe 
(using  a  solution  of  bicarbonate  of  soda,  3J-OJ),  if  the  mem- 
brane is  yet  in  the  early  stages  of  the  affection,  but  little, 
if  any  difference  will  be   observed,   as   compared  with   the 
normal  state;   immediately  after  the  cleansing  operation,  the 
membrane    may  appear    somewhat    congested,   but    after  a 
short  while,  this   passes   away,  and  the  membrane   appears 
even  paler  than  usual.     In  the  second  stage,  the  irregulari- 
ties of  the   surface   may  appear  more   marked,  or  the  con- 
trary may  be   the   case,   the   crypts   and   depressions  being 
filled  out,  as  it  were,  and  appearing  as  if  flush  with  the  sur- 
rounding parts.     A  rough,  granular  aspect  is  often  presented, 
the  edges  of  the   Eustachian  tube   openings  presenting  the 
same   appearance.     In   advanced  cases,  the   naso-pharyngeal 
wall  generally  presents  a  shrunken  appearance,  its  dry,  glist- 
ening surface  contrasting  markedly  with  the  moist  appear- 
ance of  the   earlier  stages.     A   sensation  of  great  dryness, 
which   extends   to   the  lower  pharynx,  is  a  source  of  great 
annoyance  to  the  patient. 

Prognosis. — Chronic  post-nasal  catarrh  cannot  be  consid- 
ered as  dangerous  to  life  in  itself,  but  there  is  no  doubt 
that  its  presence  so  undermines  the  system  as  to  reduce 
markedly  its  resisting  power  to  disease,  rendering  it  sus- 
ceptible, therefore,  to  affections  to  which  otherwise  it  would 
not  be  liable.  As  a  focus  of  inflammation,  it  is  a  dan- 
gerous neighbor  for  the  surrounding  parts,  the  pharynx, 


CHRONIC   POSTERIOR  NASAL  PHARYNGITIS.  223 

larynx,  and  the  lungs  even,  being  constantly  exposed  to 
contamination  through  continuity  of  tissue.  The  disease 
principally  affects  young  people,  frequently  disappearing 
about  middle  life. 

Treatment. — The  therapeutic  measures  to  be  adopted  vary, 
of  course,  with  the  cause  of  the  trouble  in  each  individual 
case.  The  cause  must  first  carefully  be  sought  for,  and 
eradicated  if  possible,  the  success  of  the  treatment  depend- 
ing upon  the  effectiveness  with  which  this  is  accomplished. 
In  other  words,  turgescences,  hypertrophies,  polypi,  deviated 
septa,  etc.,  must  be  cured  in  order  to  render  a  complete 
recovery  possible.  Any  diathetic  condition  must  also  receive 
attention.  The  abnormal  conditions  which  may  be  met 
with  in  the  anterior  nasal  cavities  have  been  described; 
the  reader  is  therefore  referred  to  the  chapters  containing 
them  for  the  means  to  be  adopted. 

While  the  treatment  for  the  anterior  primary  trouble  is 
progressing,  the  naso-pharynx  may  also  receive  attention. 
Cleanliness  is  of  course  an  important  desideratum,  as  is  the 
case  in  all  affections  accompanied  by  abnormal  secretion. 
The  proper  performance  of  this  part  of  the  treatment,  how- 
ever, is  not  always  easy.  Ablutions  through  the  nose  are 
not  satisfactory;  they  do  not  effectively  cleanse  the  naso- 
pharyngeal  membrane  of  the  discharges  which  adhere  tena- 
ciously to  them.  The  cleansing  must  be  conducted  pos- 
teriorly, the  tip  of  the  instrument  used  being  introduced 
behind  the  soft  palate.  The  patient  must  be  taught  the 
manipulation,  so  as  to  enable  him  to  conduct  it  several  times 
daily  if  necessary.  In  cases  in  which  the  discharges  are 
not  difficult  to  remove,  the  atomizer  is  the  most  satisfactory 
instrument.  In  my  office,  I  employ  Sass'  tubes  (P'ig.  17) 
which  throw  a  rather  coarse  spray  and  cleanse  the  cavity 
effectively  and  rapidly.  The  straight  tips  of  these  iustru- 


224 


DISEASES    OF   THE   POSTERIOR   NASAL   CAVITY. 


meiits,  however,  prevent  their  introduction  behind  the  soft 
palate,  and  they  cannot  be  used  effectively  by  the  patient, 
the  frequent  approximation  of  the  velum  palati  to  the 
pharynx  preventing  the  passage  of  the  spray.  The  instru- 
ment represented  in  Fig.  60  is  the  one  I  usually  prescribe 


Fig.  60. 


Post-nasal  atomizer. 


for  patients,  an  ordinary  perfume  atomizer  with  a  long  tip 
curved  upward.  The  patient  readily  learns  how  to  intro- 
duce its  point  behind  the  soft  palate,  the  curved  end  being 
so  rounded  as  not  to  wound  the  soft  membrane  of  the 
parts.  When  the  crusts  are  detached  with  difficulty,  Hall's 


CHRONIC   POSTERIOR   NASAL   PHARYNGITIS.  225 

syringe  is  required,  employing  as  a  tube  that  shown  in  Fig. 
30,  which  also  represents  exactly  the  latter's  position  in  the 
nose,  when  used. 

The  cleansing  solution  recommended  for  anterior  nasal 
affections,  pages  75  and  118  having  given  greater  satisfaction 
than  others  tried;  I  also  employ  them  for  the  nasopharynx. 
The  first  is  indicated  in  the  first  and  second  stages  of  the 
disease,  while  the  second  solution  can  be  employed  in  the 
third,  when  fetor  forms  an  element  of  the  symptoms. 

In  some  cases,  the  treatment  of  the  primary  cause,  and 
the  salutary  effects  of  either  of  the  solutions  employed  in 
the  naso-pharynx,  are  sufficient,  after  a  period  varying 
from  six  months  to  one,  two,  and  occasionally  three  years, 
to  bring  about  a  comparatively  healthy  condition  of  the 
parts,  although  relief  is  experienced  from  the  start.  In 
the  majority  of  cases,  however,  the  treatment  must  be 
'  pushed  with  more  vigor,  and  local  applications  in  the 
form  of  powders,  glycerites,  or  solutions  may  be  used  with 
advantage. 

Powders  are  especially  beneficial  when  the  discharge  is 
copious  and  not  inclined  to  form  scabs.  When  the  anterior 
cavities  are  large,  the  auto-insufflator  (Fig.  27)  can  be  used 
most  conveniently  by  the  patient,  who  can,  by  means  of 
sudden  blasts,  distribute  the  powder  over  the  surface  of  the 
vault.  Few  patients,  however,  have  such  roomy  noses;  the 
majority  of  cases  require  an  insufflator  with  \vhich  they  can 
medicate  the  parts  through  the  mouth,  and  the  use  of  which 
they  can  readily  learn. 

The  little  instrument  shown  in  Fig.  61  has  proven  very  satis- 
factory for  the  purpose.  It  consists  of  a  hard  rubber  tube,  the 
tip  of  which  is  bent  upward  and  flattened.  The  other  end 
is  also  turned  upward,  to  prevent  the  escape  of  the  powder 
into  the  bulb  when  the  instrument  is  accidentally  held  per- 

15 


226 


DISEASES   OF   THE   POSTERIOR   NASAL   CAVITY. 


peudicularly ;  the  portion  pointing  upward  is  curved  and 
connected  with  the  tube  of  a  rubber  bulb.  A  hole  through 
the  upper  surface  of  the  tube  serves  for  the  introduc- 
tion of  the  powder.  When  the  instrument  is  used,  the 
powder  is  introduced  and  the  hole  is  closed  with  the  end 
of  the  index  finger,  the  thumb  being  under.  The  instru- 
ment is  then  passed  into  the  mouth,  the  tip  introduced 


Fig.  61. 


Author's  posterior  auto-insufflator. 

behind  the  soft  palate,  and  a  slight  compression  of  the 
rubber  bulb  with  the  left  hand,  will  drive  the  powder  to  the 
desired  spot.  Patients  learn  the  manipulation  without  diffi- 
culty, although  the  first  two  or  three  trials  cause  slight 
retching  in  some  cases.  The  cheapness  of  this  instrument 
places  it  within  the  reach  of  even  poor  patients.  For  office 
purposes,  when  medicines  which  do  not  require  exact  dosage 
are  employed,  I  use  Dr.  A.  H.  Smith's  powder  insufflator 
(Fig.  26),  using  the  curved  tip. 


CHRONIC   POSTEKIOK  NASAL   PHARYNGITIS.  227 

In  the  early  stages  of  the  affection,  a  powder  composed 
of  one-quarter  of  a  grain  of  nitrate  of  silver  to  three 
grains  of  bismuth,  closely  triturated,  applied  night  and 
morning  after  cleansing,  has  proven  very  effective.  After  a 
couple  of  weeks,  the  silver  nitrate  can  be  increased  to  one- 
half  grain  to  the  powder.  In  using  this  medicine,  however, 
the  danger  of  argyria  should  be  remembered;  it  is  best  to 
cease  its  use  after  one  month,  and  resort  to  some  other 
agent  for  some  time.  Oxide  of  zinc  has  seemed  to  me  to 
keep  up  the  action  of  the  nitrate  of  silver  most  satisfactorily, 
one  grain  being  used  with  three  grains  of  sugar  of  milk  at 
each  application.  After  one  month,  the  use  of  the  silver 
can  be  resumed.  Calomel  is  especially  effective  when  the 
affection  is  due  to  a  scrofulous  diathesis,  one  grain  with 
three  of  bismuth  applied  twice  daily  having  proven  efficient 
in  a  number  of  cases. 

When  the  case  has  so  far  progressed  that  the  discharges 
have  become  muco-purulent,  boracic  acid,  one  grain  with 
as  much  bismuth,  has  been  found  very  useful.  It  modifies 
the  character  of  the  discharge  after  a  few  weeks'  steady  use, 
after  which  the  treatment  for  the  first  stage  can  be  substi- 
tuted. In  some  cases,  an  astringent,  such  as  tannic  acid, 
either  used  pure  or  with  equal  parts  of  bismuth,  exerts  a 
powerful  influence  upon  the  membrane,  but  it  cannot  be 
borne  by  every  patient,  occasionally  increasing  the  inflam- 
mation. In  these  cases,  the  addition  of  powdered  bella- 
donna, half  a  grain  to  the  powder,  or  one-eighth  of  a  grain 
of  morphia,  added  to  each  application,  prevents  too  active 
stimulation  and  promotes  the  absorption  of  inflammatory 
products. 

In  cases  in  which  desiccated  crusts  are  discharged,  liquid 
applications  alone  should  be  used,  after  cleansing  the  parts 
very  thoroughly.  A  preparation  which  has  been  of  great 


228  DISEASES   OF   THE   POSTERIOR   NASAL   CAVITY. 

benefit  in  such  cases  is  the  glycerite  of  carbolized  iodo- 
tannin,  described  on  page  76.  Here,  however,  it  should  be 
used  at  half  strength,  four  ounces  of  glycerine  being  added, 
instead  of  two.  For  its  application,  the  instrument  repre- 
sented in  Fig.  62,  an  appropriately  curved  wire  mounted  in  a 
wooden  handle,  is  used.  Its  tip,  wrhich  is  somewhat  rough- 
ened, serves  for  the  attachment  of  a  piece  of  cotton  wool. 
It  can  be  used  with  facility  by  the  patient,  who  should 
be  taught  the  manipulation  as  it  is  described  page  44. 
The  sulphate  of  copper  solution  (gr.  iij-^j)  is  another  val- 
uable agent,  which,  alternated  now  and  then  with  the  for- 
mer, sometimes  advances  markedly  the  favorable  result. 


Fig.  62. 


Posterior  pharyngeal  applicator. 

Sulphate  of  zinc  (gr.  v-!j),  acetate  of  lead  (gr.  v-!j)  or  chlo- 
ride of  zinc  (gr.  iij-^j)  may  also  be  used  advantageously, 
according  to  indications.  Warm  vaseline  administered  with 
the  atomizer,  strongly  recommended  by  Glasgow,  of  St. 
Louis,  has  also  proven  satisfactory  in  my  hands. 

In  the  majority  of  cases  of  aggravated  post-nasal  catarrh, 
internal  treatment  is  of  the  greatest  importance.  When 
scrofula  is  an  element  of  the  trouble,  syrup  of  the  iodide 
of  iron,  administered  as  in  scrofulous  rhinitis,  syrup  of  the 
hypophosphites,  or  tonic  doses  of  bichloride  of  mercury  (gr. 
?*),  iron,  quinine,  and  strychnia,  may  be  used,  according  to 
the  necessities  of  the  case.  The  hydrated  chloride  of  cal- 


HYPERTROPHIC   POSTERIOR  NASAL  PHARYNGITIS.  229 

cium,  ten  or  more  grains  three  times  daily,  as  recom- 
mended by  Cohen,  has  given  excellent  results  in  a  number 
of  cases. 

Agents  which  are  partly  eliminated  through  the  glands 
of  the  throat  and  nose,  when  taken  internally,  are  some- 
times very  serviceable  in  assisting  the  curative  measures 
by  modifying  the  character  of  the  discharges.  Of  these, 
cubebs  is,  in  my  opinion,  the  most  effective.  It  may  be  ad- 
ministered in  the  form  of  powder,  three  grains  being  given 
in  syrup  of  ginger  and  water,  after  meals;  or,  the  oleosin 
may  be  employed,  fifteen  drops  on  a  lump  of  sugar  also 
three  times  a  day  and  after  meals. 

Ammoniacum  in  very  small  doses  (gr.  j.-iij)  is  much  lauded 
by  Beverly  Robinson,  administered  with  an  expectorant  such 
as  ipecac  or  carbonate  of  ammonia.  In  cases  in  which  the 
stomach  rebels  against  cubebs,  it  may  be  used  as  an  excel- 
lent substitute. 

The  presence  of  malaria  in  the  system  interferes  greatly 
with  the  progress  of  the  case,  apparently  neutralizing  the 
therapeutic  measures.  The  exhibition  of  quinine  is  of  course 
indicated,  and  should  be  continued  until  all  traces  of  the 
malaria  have  completely  disappeared. 

HYPERTROPHIC   POSTERIOR   NASAL   PHARYNGITIS. 

(Synonyms : — Adenoid    Vegetations    at    the    Vault   of    the    Pharynx ; 
Adenomata   of  the    Pharynx.) 

Etiology. — Hypertrophy  of  the  glandular  tissue  of  the 
naso-pharynx  occurs  principally  in  childhood  and  adoles- 
cence. It  is  seldom  seen  after  the  age  of  thirty,  and  does 
not  seem  to  be  due  to  any  special  diathesis,  although,  as 
shown  by  Lowenberg,  a  lymphatic  temperament  seems  to 
predispose  to  it.  The  origin  is  probably  traceable  in  all 


230  DISEASES   OF   THE   POSTERIOK   NASAL    CAVITY. 

cases  to  a  catarrhal  state  of  the  naso-pharynx,  the  causes 
of  the  latter  being  therefore  the  primary  etiological  factors. 
Heredity  is  undoubtedly  an  element  in  many  cases.  In  this 
country,  it  seems  to  be  oftener  prevalent  among  females 
than  males. 

Pathology. — The  analogy  between  the  glandular  tissue  of 
the  vault  of  the  pharynx  and  the  tonsils,  which  caused 
Luschka  to  term  the  former  the  "pharyngeal  tonsil,"  ren- 
ders it  probable  that  the  liability  to  hypertrophic  changes 
to  which  the  tonsils  are  susceptible  in  some  persons,  exists 
also  in  the  pharyngeal  tonsil,  and  that  a  continued  or  often 
repeated  inflammatory  process  may  also  act  as  an  exciting 
cause.  The  inherent  deficiency  of  recuperative  powers 
peculiar  to  lymphatic  glandular  tissue  being  an  important 
element  in  the  pathology  of  this,  as  it  is  in  simple  chronic 
inflammation,  the  hypertrophic  process  is  but  a  result  of 
the  continued  hyperplasia.  Microscopically,  the  growths 
consist  mainly  of  the  adenoid  tissue  of  His,  which  contains 
quantities  of  lymph  cells,  some  conglomerate  glands  and 
follicles,  and  is  freely  supplied  with  blood-vessels. 

Symptoms. — The  most  prominent  symptom  of  glandular 
hyperplasia  is  due  to  the  interference  with  the  passage  of 
the  sound  waves  through  the  posterior  nasal  cavity  which 
the  growth  occasions.  It  consists  of  a  peculiar  deadness 
of  the  voice,  a  want  of  resonance  which  causes  it  to  sound 
as  if  the  words  were  spoken  into  a  tumbler  held  horizontally 
with  its  rim  close  to  the  mouth.  This  muffled  condition  of 
the  voice  is  accompanied  with  a  nasal  intonation,  resembling 
somewhat  the  "nasal  twang"  but  it  is  deprived  of  the  ringing 
character  which  the  latter  sometimes  possesses;  the  patient 
is  said  to  talk  "thick."  As  a  rule,  the  nasal  respiration  is 
not  impeded,  but  when  the  growths  are  large,  a  feeling  of 
obstruction  is  experienced,  especially  marked  during  inspi- 


HYPERTROPHIC   POSTERIOR  NASAL   PHARYNGITIS.  231 

ration,  and  when  an  accumulation  of  mucus  diminishes  the 
lumen  of  the  cavity.  When  the  growths  are  very  large, 
however,  respiration  through  the  nose  is  rendered  difficult, 
and  the  patient  is  obliged  to  breathe  through  the  mouth, 
to  the  detriment  of  the  pharynx  and  larynx. 

The  discharge  is  not,  as  a  rule,  as  important  an  element 
of  the  case  as  in  simple  posterior  chronic  nasal  pharyngitis. 
It  is  usually  that  described  when  speaking  of  the  first  stage 
of  the  latter  affection,  a  thick,  whitish,  gluey  substance, 
which  is  sometimes  tinged  with  blood.  Occasionally,  it  as- 
sumes a  purulent  character,  and  scabs  are  formed  which 
desiccate  in  situ,  and  are  usually  "hacked"  into  the  mouth 
and  expectorated,  leaving  the  underlying  surface  somewhat 
abraded,  with  a  tendency  to  bleed.  Aural  complications 
are  frequently  present,  due  in  some  cases  to  pressure  upon 
or  occlusion  of  the  mouth  of  the  Eustachian  tubes,  and  in 
others  to  extension  of  the  catarrhal  inflammation  into  them. 

The  appearances  of  the  growths  vary  greatly  in  different 
cases.  In  some  they  resemble  a  cushion,  extending  from 
the  posterior  nares  along  the  roof  and  upper  part  of  the 
naso-pharynx  to  within  a  short  distance  above  the  level  of 
the  soft  palate,  more  or  less  deep  crypts  and  depressions 
rendering  its  surface  irregular.  In  others  they  present  the 
form  of  rounded  bodies  resembling  small  pink  beans,  which 
hang  in  clusters  from  the  roof  of  the  cavity  and  hide  from 
view  the  upper  portion  of  the  posterior  nares.  Frequently 
the  mass  is  greater  on  one  side  of  the  cavity  than  on  the 
other,  and  is  sometimes  sufficiently  large  to  press  upon  the 
mouths  of  the  Eustachian  tubes  and  even  to  obliterate  their 
openings.  Their  color  is  light  pink,  which  becomes  red 
when  subjected  to  manipulation  with  the  probe,  or  by  the 
use  of  cleansing  solutions. 

When  the  rhinoscope   cannot   be  used,  as  in  children  for 


232  DISEASES    OF   THE   POSTEIUOK   NASAL   CAVITY. 

instance,  the  examination  can  be  conducted  with  the  index 
finger  passed  behind  the  soft  palate.  As  indicated  by  Meyer, 
of  Copenhagen,  the  sensation  communicated  to  the  finger 
when  the  grape-like  or  fimbriated  variety  is  met  with,  is 
that  experienced  when  the  finger  is  applied  to  a  mass  of 
earth-worms.  In  the  cushion-like  variety,  a  soft,  smooth 
surface  is  felt,  which  contrasts  with  the  comparative  hard- 
ness of  the  surrounding  parts. 

Prognosis. — The  natural  tendency  of  these  growths  is 
to  undergo  absorption  towards  the  thirtieth  year.  Left 
to  themselves,  therefore,  they  will  gradually  disappear. 
Although  this  may  seem  to  render  therapeutic  measures 
unnecessary,  the  impaired  enunciation  and  the  danger  to 
the  hearing,  besides  other  complications  which  might  arise, 
are  sufficient  to  warrant  the  employment  of  active  treat- 
ment. 

Treatment. — Removal  of  the  growths  by  surgical  means  is 
the  only  effective  procedure.  When  the  vegetations  are  not 
large,  galvano-cautery  may  be  used  with  advantage.  A 
suitably  bent  electrode,  with  a  small  loop  presenting  a  burn- 
ing surface  about  as  large  as  a  pea  and  covered  by  a  hood, 
to  prevent  burning  of  the  surrounding  parts,  is  passed 
behind  the  soft  palate  and  located  against  the  most  promi- 
nent portion  of  the  growth.  The  current  being  then  turned 
on,  the  white-hot  metal  is  left  in  contact  with  the  mass  a 
couple  of  seconds.  The  electrode  is  then  moved  slightly, 
and  another  cauterization  is  applied,  this  procedure  being 
repeated  three  or  four  times,  without  removing  the  instru- 
ment. Slight  bleeding  generally  follows  the  operation,  which 
is  painless  and  not  followed  by  disagreeable  after-effects. 
After  a  few  days,  it  can  be  renewed  until  the  exuberant 
tissue  has  been  destroyed. 

The   instrument   represented    in    Fig.  44,   used  with    the 


HYPERTROPHIC   POSTERIOR  NASAL  PHARYNGITIS. 


233 


curved  tip,  is  very  convenient  for  the  extirpation  of  large 
growths  by  snaring.  Introduced  with  the  loop  hidden  in 
the  tube,  the  tip  is  placed  behind  the  mass  which  is  to  be 
cut  off.  The  loop  being  then  formed  by  separating  the 
rings,  it  encircles  the  mass,  which  can  then  either  be 


Author's  post-nasal  cautery  loop  in  position. 

gradually  or  suddenly  cut  off.  The  operation  presents  the 
advantages  of  being  easily  performed  and  of  being  abso- 
lutely free  from  all  danger.  For  suitable  cases,  the  straight 
end  may  be  used  by  passing  it  through  the  anterior  nares. 
It  is  only  applicable,  however,  in  the  fimbriated  variety  of 
vegetations,  the  cushion-like  masses  not  being  seizable  by 


234  DISEASES   OF   THE   POSTEKIOK   NASAL   CAVITY. 

the  loop.  The  cautery  snare  can  also  be  used,  but  the 
proximity  of  the  Eustachian  tubes  renders  its  use  more 
dangerous  than  other  less  complicated  methods.  The  in- 
strument shown  in  Fig.  64  can  be  used  with  advantage  in 
any  ease,  but  its  manipulation  requires  care.  The  extremi- 
ties of  the  blades  are  cup-shaped  and  sharp,  and  when  they 
are  introduced  into  the  vault,  the  part  seized  is  cut  off.  In 
pillow-like  vegetations  the  sharp  end  is  pressed  into  the 
mass,  and  when  the  blades  are  approximated,  a  piece  is 
pared  off,  leaving  a  deep  furrow.  Considerable  bleeding 
follows  in  some  cases,  but  this  stops  after  a  few  moments. 
Fhnbriated  tumors  can  be  grasped  with  ease,  and  generally 


Cohen's  post-nasal  cutting  forceps. 

bleed  but  slightly  if  at  all.  The  rhinoscope  should  always 
be  used  to  guide  the  instrument.  Several  operations  are 
necessary,  at  five  or  six  days'  interval. 

Guye,  of  Amsterdam,  uses  his  finger-nails  to  scrape  the 
growths  away,  a  method  which  presents  advantages  in  chil- 
dren. Capart,  of  Brussels,  uses  a  curette,  connected  with 
the  end  of  the  finger  by  means  of  a  double  cylinder,  which 
also  acts  as  a  finger  shield. 

NASO-PHAKYNGEAL  POLYPUS 

Etiology. — Polypi  located  in  the  naso-pharynx  are  rarely 
met  with.  They  usually  occur  between  the  ages  of  five  and 
twenty-five,  and  are  more  frequently  developed  in  males 


NASO-PHARYNGEAL   POLYPUS.  235 

than  females.  Morell  Mackenzie  believes  them  to  be  due 
"to  an  irregular  evolution,  during  the  growing  period,  of 
a  tissue  which,  under  normal  conditions,  is  exceptionally 
abundant  on  the  under  surface  of  the  base  of  the  skull ;" 
a  fact  rendered  probable  by  the  predilection  of  the  growths 
for  the  time  of  life  during  which  development  takes  place, 
and  their  tendency  to  spontaneous  absorption  after  the  de- 
velopment has  been  accomplished. 

Pathology. — Naso-pharyngeal  polypi,  like  the  fibrous  growths 
occurring  in  the  anterior  nasal  cavities,  arise  from  the  peri- 
osteum or  from  connective  tissue,  and  present  the  same 
pathological  characters  as  similar  growths  in  other  situa- 
tions :  fibrous  tissue,  closely  interlaced  or  grouped  in  bun- 
dles of  various  sizes,  interspersed  with  small  vessels  whose 
coats  are  easily  torn. 

Symptoms. — The  early  symptoms  of  naso-pharyngeal  polypus 
are  those  of  an  advanced  case  of  adenoid  vegetations  in  the 
naso-pharynx,  just  described — more  or  less  embarrassed  nasal 
respiration,  nasal  voice  and  profuse  mucoid  discharges.  As 
the  case  progresses,  the  symptoms  become  more  accentuated 
until  respiration  through  the  nose  becomes  impossible,  and 
the  voice  so  altered  as  to  be  almost  unintelligible.  The  dis- 
charge increases  in  quantity  and  is  frequently  sanguinolent, 
the  blood  arising  not  only  from  the  tumor  itself,  but  also 
from  the  surrounding  parts,  which  are  compressed.  If  the 
polypus  grows  downward,  deglutition  becomes  difficult,  and 
nausea,  cough,  shooting  pains  in  different  parts  of  the  head 
and  chest  may  occur  through  reflex  irritation.  When  the 
polypus  advances  toward  the  anterior  cavities,  hearing  soon 
becomes  impaired  through  pressure  upon  the  Eustachian 
orifices,  and  frequent  cephalalgia,  especially  located  on  the 
top  of  the  head,  is  complained  of.  As  the  tumor  grows,  it 
penetrates  into  the  nearest  cavity,  making  room  for  itself 


236  DISEASES    OF   THE   POSTEHIOR   NASAL   CAVITY. 

by  displacing  and  destroying  bone  and  cartilage  through 
pressure,  sometimes  sending  prolongations  on  all  sides, 
and  distorting  the  features  fearfully  in  some  cases;  the 
more  frequent  disfigurement  is  a  separation  of  the  nasal 
bones,  which  induces  the  characteristic  "  frog  face."  Fibrous 
polypi  are  dark  pink  or  red,  and  usually  covered  by  a  net- 
work of  vessels  which  grow  larger  as  they  approach  the 
seat  of  implantation.  They  are  usually  attached  by  a 
moderately  broad  base,  the  diameter  of  which  is  that  of  the 
growth  for  some  distance.  They  are  hard  and  resisting. 

Prognosis. — A  naso-pharyrigeal  polypus  growing  after  the 
twentieth  year,  is  not  likely  to  attain  sufficient  size  to  cause 
a  fatal  issue.  As  the  process  of  growth  ceases,  that  of  the 
tumor  ceases  also,  and  it  may  even  be  completely  ab- 
sorbed. Earlier  in  life,  if  left  to  itself,  the  growth  steadily 
increases  until  the  patient  succumbs. 

Treatment. — If  seen  early  the  evulsion  of  a  naso-pharyn- 
geal  polypus  cannot  be  said  to  be  difficult.  The  hardness 
of  the  mass  and  its  tendency  to  copious  bleeding  when 
lacerated,  preclude  the  use  of  the  forceps,  although  these  are 
used  by  some  surgeons,  who  employ  a  strong,  curved  instru- 
ment which  is  passed  behind  the  soft  palate.  The  snare, 
galvanic  or  cold,  is  in  my  opinion  the  best  instrument  at 
our  disposal.  If  sufficient  time  be  taken  for  the  operation, 
but  little  if  any  blood  is  lost,  and  the  pain  to  which  the 
patient  is  subjected  is  trifling,  while  cocaine,  applied  thor- 
oughly to  the  parts,  renders  the  operation  painless.  A 
curved  canula  is  required  if  the  operation  is  to  be  performed 
through  the  mouth,  while  the  ordinary  straight  tube  can  be 
used  through  the  nasal  cavities.  The  selection  of  either 
depends,  of  course,  upon  the  position  of  the  tumor  and  its 
shape.  When  the  polypus  grows  from  the  roof  of  the  cavity 
and  hangs  downward,  the  operation  is  best  performed  through 


NASO-PHARYNGEAL   POLYPUS.  237 

the  nose,  the  loop  being  adjusted  as  near  as  possible  to  the 
seat  of  implantation  by  a  finger  passed  behind  the  soft 
palate,  and  held  there  until  firm  grasp  is  obtained.  One 
hour  at  least,  should  be  employed  to  gradually  penetrate 
the  growth  if  the  cold  snare  is  used,  while  somewhat  less 
time  is  needed  with  the  cautery  snare,  which  cauterizes  the 
cut  surface.  When  the  tumor  grows  upon  the  posterior 
surface  of  the  vault,  pointing  towards  the  posterior  nares, 
the  operation  through  the  mouth  will  alone  enable  the  loop 
to  sever  it  close  to  its  point  of  attachment.  Here,  again,  the 
finger  should  be  used  to  apply  the  wire  to  the  proper  posi- 
tion. When  the  growth  is  sessile  and  cannot  be  grasped,  a 
curved  transfixing  needle  can  be  passed  through  it,  its  in- 
troduction being  conducted  with  the  assistance  of  the  rhi- 
noscope. 

When  the  polypus  is  almost  penetrated  by  the  loop,  it 
should  be  secured  with  a  curved  volcella  forceps,  to  pre- 
vent its  falling  into  the  larynx  when  detached.  Large 
growths  with  numerous  attachments  require  more  space 
than  the  natural  openings  for  their  extirpation,  and  either 
of  the  operations  of  Rouge  or  Oilier,  which  have  already 
been  alluded  to,  may  be  required;  or,  the  soft  palate  may 
be  divided  and  the  hard  palate  trephined,  as  practiced  by 
Nelaton.  Other  operations  of  even  greater  magnitude  have 
sometimes  to  be  resorted  to. 

Electrolysis  has  occasionally  succeeded  in  destroying  naso- 
pharyngeal  polypi.  Cohen's  needle,  which  is  covered  by  a 
non-conducting  material,  is  the  most  convenient  instrument 
for  the  purpose.  It  should  be  connected  with  the  negative 
pole  of  a  moderately  strong  battery,  the  positive  pole  being 
placed  over  the  sternum.  Each  application  should  be  re- 
newed every  other  day,  the  sittings  lasting  from  ten  minutes 
to  one-half  hour. 


238  DISEASES   OF    THE   POSTERIOR   NASAL   CAVITY. 

Injections  of  iodine  or  ergotino  may  be  used  to  en- 
courage absorption,  or  actual  cautery  or  caustic  acids  may 
be  employed  to  induce  suppuration  and  shrinkage. 


PLATE  v. 


PLATE   V. 

FIGURE  1. — Male,  a>t.  21;  anterior  view  of  extensive  osteoenohondroma  of  sep- 
tum, occluding  completely  left  nasal  cavity:  mass 'reduced  with  dental  engine.  Case 
referred  by  Dr.  C.  S.  Turnlmll. 

FIGURE  2. — Lateral  view  of  above. 

FIGURE  ;>. — Male,  a?t.  21 ;  posterior  view  of  assvrnetrical  nasal  cavities  of  above 
case;  complete  stenosis  of  the  left  naritun. 


FIGURE  4. — Male,  ret.  11;  anterior  view  of  deviation  of  septum  to  right,  causing 
partial  occlusion  of  cavity.  Case  referred  by  Dr.  M.  O'Hara. 

FIGURE  5. — Lateral  view  of  above,  showing  concavity  of  septum  anteriorly,  and 
a  convexity  posteriorly,  due  to  abnormal  thickness  of  the  septum. 

FIGURE  G. — Posterior  view  of  above,  showing  the  thickened  septum  pressing  on 
left  middle  and  inferior  turbinated  bodies,  causing  asthma.  Thickness  reduced  with 
surgical  engine,  passing  burr  under  the  mucous  membrane  ;  asthma  relieved. 


FIGURE  7. — Male.  ast.  48  ;  relaxation  of  soft  palate,  causing  symptoms  of  elongated 
uvula ;  astringents  found  useless ;  amputation  of  uvula. 

FIGURE  8. — Female,  a?t.  '22  ;  elongation  of  uvula,  causing  cough,  expectoration, 
etc.,  and  general  symptoms  of  phthisis :  amputation  ;  complete  relief. 

FIGURE  9. — Female,  ret.  27. — Position  of  mouth  in  forcible  separation  of  jaws 
during  tonsillitis ;  further  examination  impossible ;  diagnosis  established  by  character 
of  pain,  color  of  tongue,  odor  of  breath,  and  odynphagia. 

FIGURE  10. — Male,  jet.  28;  hypertrophy  of  the  tonsils;  amputation  with  tonsillo- 
tome. 

FIGURE  1 1. — Appearance  of  tonsils  in  above  case  during  an  attack  of  tonsillitis. 


[NOTE.— Represented  as  seen  by  gas-light.     By  day-light,  the  red  color  appears  much  paler.] 


Plate    V 


C  E  Sajous,  Pinx.it. 


Wf1.6uTi.ert  Av 


CHAPTER  XIII. 

ANATOMY   AND   PHYSIOLOGY   OF   THE   PHARYNX. 


ANATOMY. 
THE     PHARYNX. 

As  generally  considered,  the  pharynx  is  that  portion  of 
the  pharyngeal  cavity  situated  between  the  nasopharynx, 
or  posterior  nasal  cavity,  which  extends  to  the  level  of 
the  soft  palate  above,  and  the  laryngo-pharynx,  which 
begins  on  a  plane  with  the  greater  cornua  of  the  hyoid 
bone  and  extends  to  the  lower  border  of  the  cricoid  car- 
tilage below.  In  contra-distinction  to  the  naso-pharynx 
and  the  laryngo-pharynx,  it  is  sometimes  called  the  oro- 
pharynx.  In  the  adult  it  extends  about  two  inches  per- 
pendicularly and  presents  to  the  eye  of  the  observer  a 
more  or  less  concave  surface,  with  a  slight  central  and  per- 
pendicular convexity,  well  marked  in  aged  individuals.  Its 
breadth  is  about  one  and  a  half  inches.  The  side  of  the 
pharynx  is  connected  with  the  posterior  half  arch,  which 
extends  from  the  posterior  aspect  of  the  soft  palate  on 
each  side,  and  is  formed  by  the  fold  of  mucous  membrane 
covering  the  palato-pharyngeus  muscle.  These  folds  are 
sometimes  called  the  posterior  pillars  of  the  fauces,  on  ac- 
count of  their  resemblance  to  the  pillars  of  an  archway, 
and  in  contra-distinction  to  the  anterior  pillars  or  anterior 
half  arch,  or  palato-glossal  folds,  which  are  formed  by  the 
palato-glossus  muscle,  and  extend  from  the  anterior  aspect 
of  the  soft  palate  to  the  side  of  the  tongue. 

The  mucous  membrane  lining  the  pharynx  proper  ad- 

(239) 


240       ANATOMY  AND  PHYSIOLOGY  OF  THE  PHARYNX. 

heres  closely  to  the  constrictor  muscles,  which  in  turn  are 
separated  from  the  cervical  vertebra  and  the  strong  apo- 
neurosis  which  covers  them,  by  cellular  tissue.  Laterally, 
it  overlies  the  carotids  and  the  internal  jugular  veins,  the 
pneumogastric  and  eighth  pair  of  nerves,  lymphatics,  and 
ganglia.  Its  epithelium  is  of  the  squamous  variety,  and 
compound  follicular  glands  are  distributed  over  its  surface. 

Vessek. — The  arteries  which  supply  the  pharynx  are  de- 
rived from  the  ascending  pharyngeal  branch  of  the  external 
carotid,  and  the  ascending  palatine  branch  of  the  facial 
artery.  A  few  twigs  from  the  internal  maxillary  may  also 
be  found. 

Nerccs. — The  nervous  supply  is  derived  from  the  pharyn- 
geal plexus  and  branches  of  the  pneumogastric  nerves  and 
the  spheno-palatine  ganglion. 

THE    SOFT    PALATE. 

The  soft  palate,  or  velum  pendulum  palati,  is  a  movable, 
curtain-like  musculo-membranous  fold  suspended  from  the 
posterior  border  of  the  hard  palate.  During  nasal  res- 
piration it  stands  some  distance  from  the  pharynx,  and  the 
interval  between  it  and  the  latter  is  termed  the  isthmus, 
already  alluded  to.  Its  border,  which  hangs  free  across 
and  above  the  base  of  the  tongue,  forms  the  upper  part  of 
the  arch,  and  is  subdivided  into  two  smaller  archways  (the 
anterior  and  posterior  pillars  already  described)  by  the 
uvula,  a  nipple-like  protuberance  suspended  in  the  middle, 
and  possessing  also  free  mobility. 

The  soft  palate  is  connected  with  the  surrounding  parts 
by  means  of  the  tensor  palati,  levator  palati,  palato-glossi 
and  palato-pharyngeus  muscles,  and  is  covered  anteriorly 
and  posteriorly  by  mucous  membrane.  Its  anterior  surface 
is  freely  supplied  with  racemose  glands.  The  uvula  con- 


THE  TONSILS.  241 

tains  the  azygos  uvulae  muscle  which  draws  it  up  to  com- 
pletely close  the  isthmus,  and  is  also  covered  by  a  com- 
paratively thick  layer  of  mucous  membrane. 

THE   TONSILS. 

The  tonsils  are  two  almond-shaped  bodies  lying  between 
the  anterior  and  posterior  pillars,  one  on  each  side.  Each 
tonsil  is  about  nine  lines  long  and  six  lines  wide,  and  its 
thickness  is  usually  so  limited  in  the  normal  condition  as 
to  render  its  examination  very  difficult.  Its  surface,  which 
is  invested  with  pavement  epithelium,  is  studded  with  from 
twelve  to  fifteen  depressions,  the  lacunce,  which  penetrate 
deeply  into  the  surface  of  the  gland,  and  are  covered  by 
reduplications  of  the  mucous  membrane,  thickly  furnished 
with  follicles.  In  the  spaces  between  them  are  quantities 
of  small  lymphatic  glands.  The  tonsil  is  in  relation  exter- 
nally with  the  -superior  constrictor  muscle,  behind  which 
lies  the  external  carotid  artery,  from  which  it  receives  a 
branch,  sometimes  quite  large,  the  tonsillar  artery. 

Physiology. — The  physiological  functions  of  the  oro- 
pharynx  are  principally  concerned  in  the  process  of  deglu- 
tition. The  contraction  of  the  constrictor  muscles,  under- 
neath, propels  the  bolus  down  in  the  direction  of  the  oeso- 
phagus, while  the  follicular  glands  serve  to  lubricate  it  so 
as  to  facilitate  its  passage  to  the  stomach. 

The  soft  palate  acts  as  a  valve  which  closes  the  isthmus 
tightly  during  deglutition,  to  prevent  the  ascent  of  the  bolus 
of  food  into  the  posterior  nasal  cavity.  In  phonation,  it  also 
holds  an  important  position,  its  proximity  to  the  pharynx 
giving  or  depriving  the  voice  of  nasal  intonation  (see  page 
21).  The  uvula  serves  the  purpose  of  closing  up  tightly 
what  interval  might  exist  between  the  edge  of  the  soft  palate 
and  the  pharynx,  when  the  former  is  raised  and  adapted 
against  the  latter.  16 


CHAPTER  XTY. 

PHAKYNGOSCOPY. 

PHAHYNGOSCOPY  is  the  term  applied  to  the  optical  exami- 
nation of  the  pharynx.  The  mouth  being  widely  opened  and 
the  light  directed  into  it,  the  part  which  will  appear,  if  respi- 
ration is  continued  as  it  was  before  the  mouth  was  opened, 
i.e.,  through  the  nose,  will  be  the  anterior  surface  of  the 
soft  palate,  its  lower  border,  including  the  uvula,  being 
closely  adapted  against  the  base  of  the  tongue,  so  as  to  form 
a  direct  channel  for  the  passage  of  the  air  current  on  its 
way  from  and  to  the  lungs,  behind.  If  now  the  tongue  is 
depressed  with  a  tongue-depressor  such  as  that  shown  in 
Fig.  11,  the  edge  of  the  soft  palate  will  cease  to  touch  the 
base  of  the  tongue  (unless  the  former  be  elongated)  and  the 
patient  will  breathe  partly  through  the  mouth  and  partly 
through  the  nose.  The  soft  palate  will  appear  in  full  view, 
its  light  pink  color  contrasting  somewhat  with  the  redder 
aspect  of  the  pillars  and  the  posterior  walls  of  the  pharynx, 
which,  however,  can  only  partly  be  seen.  If  the  patient  is 
now  directed  to  breathe  forcibly  through  the  mouth,  the 
soft  palate  will  be  seen  to  rise  and  adapt  itself  closely  to 
that  part  of  the  pharynx  which  may  be  considered  as  the 
dividing  line  between  the  naso-pharynx  and  the  oro- 
pharynx.  The  latter  will  then  appear,  bounded  above  by 
the  outline  of  the  soft  palate,  laterally  by  the  posterior  pillars, 
and  below  by  the  base  of  the  tongue.  In  the  normal  state,  the 
pharynx  is  pinkish,  streaked  with  patches  of  a  lighter  hue. 
Thin  blood-vessels  may  be  seen  crossing  it  from  side  to  side 
or  obliquely,  while  its  surface  is  studded  with  minute  monti- 
(242) 


PHARYNGOSCOPY.  243 

cules  about  the  size  of  a  pin's  head,  formed  by  the  under- 
lying glands.  The  anterior  and  posterior  pillars,  when 
normal,  should  appear  sharply  denned,  and  be  of  a  pale- 
yellowish  pink  hue.  The  uvula  is  of  the  same  color. 

The  tonsils  are  usually  seen  with  difficulty  when  they  are 
not  hypertrophied.  When  they  are  visible,  their  upper  half 
only  can  generally  be  brought  to  view,  the  lower  half  being 
below  the  level  of  the  tongue.  Their  surface  is  irregular 
and  marked  by  a  number  of  depressions,  the  lacun*  or  crypts. 


CHAPTER  XV. 

INSTRUMENTS    USED    IN    CLEANSING    AND    MEDICATING    THE 

PHARYNX. 

CLEANSING  of  the  pharynx,  soft  palate  and  tonsils,  prior 
to  the  application  of  remedies,  is  almost  as  important  as  in 
the  nose.  The  most  effective  instrument  for  office  use  is 
Sass'  direct  tube  (Fig.  17).  the  pneumatic  power  being  fur- 
nished by  an  air  compressor  (Fig.  18).  In  order  to  expose 
the  pharynx  to  the  spray,  the  tongue  must  be  depressed, 
the  tongue  depressor  being  held  with  the  left  hand  while 
the  Sass  tube  is  held  with  the  right.  Two-thirds  of  the 
tongue  being  depressed,  the  patient  is  directed  to  breathe 
entirely  through  the  mouth  during  the  application,  so  as  to 
force  the  soft  palate  upward,  and  expose  as  much  as  possible 
of  the  pharynx  and  its  adjacent  parts.  The  surfaces  having 
been  thoroughly  irrigated,  a  large  piece  of  absorbent  cotton, 
held  in  the  grasp  of  a  forceps,  can  be  used  to  mop  the 
moisture  from  the  membrane,  the  medicinal  application  being 
made  immediately  after. 

When  the  patient  has  to  be  entrusted  with  the  local  treat- 
ment of  the  parts,  an  atomizer  is  required  which  can  be 
manipulated  easily  and  independently  of  an  air  condenser. 
The  hand  and  ball  arrangement  is  here  most  convenient,  but 
as  one  hand  is  required  to  operate  the  rubber  bulb  and  the 
other  to  hold  the  bottle,  an  arrangement  such  as  that  shown 
in  Fig.  65,  in  which  the  tongue-depressor  is  connected  with 
the  atomizer,  becomes  necessary.  The  apparatus  generally 
sold,  in  which  the  spray  tube  is  in  contact  with  the  tongue- 
depressor,  should  not  be  employed;  it  gags  the  patient  if 
(244) 


PHARYNGEAL   ATOMIZER. 


245 


introduced  deeply  into  the  mouth,  and  if  it  is  not,  the  spray 
impinges  upon  the  portion  of  the  tongue  beyond  the  tongue- 
depressor,  and  does  not  reach  the  pharynx. 

For  the  application  of  solutions  to  limited  portions  of  the 
pharyngeal  cavity,  the  cotton  pledget  and  the  brush  are 
mostly  employed.  For  cotton  pledgets,  the  instrument 
shown  in  Fig.  66,  is,  in  my  opinion,  the  most  satisfactory 

Fig.  65. 


Author's  pharyngeal  atomizer. 

in   every  way.     Its  grasp  is  very  safe,  while  the  simplicity 
of  its  construction  renders  its  cleansing  easy. 

For  the  patient's  use,  the  instrument  represented  in  Fig. 
67  can  be  recommended  on  account  of  its  simplicity  and 
slight  cost.  He  should  be  carefully  showTn  its  mechanism 
and  directed  to  bring  the  clasp  ring  as  closely  to  the  end 
as  possible,  when  the  cotton  pledget,  made  as  described  on 
page  45,  has  been  inserted  between  the  claws. 


240 


INSTRUMENTS   USED   IN   TREATING   THE   PHARYNX. 


The  brush,  however,  is  to  be  preferred  when  the  applica- 
tions have  to  be  made  by  the  patient.  It  should  be  flat, 
about  one-halt'  inch  in  width,  and  examined  before  each 
application,  to  ascertain  that  no  loose  hair  is  likely  to 
become  detached  and  cause  annoying  symptoms,  such  as 
cough,  nausea,  etc. 

Fig.  66. 


Cohen's  pharyngeal  cotton  holder. 

Iii  making  an  application  to  the  pharynx  with  the  pledget 
or  brush,  care  should  be  exercised  to  not  take  up  too 
great  a  quantity  of  the  fluid  used.  It  this  precaution  is 
not  observed  the  solution  is  liable  to  run  down  along  the 
pharyngeal  wall  to  the  larynx,  where  it  may  cause  spas- 
modic cough  and  irritation,  followed  by  annoying  sensa- 


Fig.  67. 


Turnbull's  cotton  holder. 


tions  of  some  duration.  The  applications  are  best  made 
from  below  upward,  a  horizontal  line  being  first  drawn 
across  the  lower  limit  of  the  application,  to  arrest  any 
rivulet  of  the  solution  that  may  form  above,  through  the 
compression  exerted  by  the  instrument  against  the  surfaces 
treated. 


INSUFFLATOES.  247 

For  the  application  of  powders,  the  scoop  insufflator  (Fig. 
25)  or  Dr.  A.  H.  Smith's  instrument  (Fig.  26),  may  be  em- 
ployed, the  straight  tip  being  adjusted.  While  applying 
powders  in  this  locality,  the  bulb  of  the  insufflator  used 
should  be  compressed  lightly  and  repeatedly,  the  applica- 
tion being  divided  into  a  series  of  light  puffs,  which,  com- 
bined, cover  the  entire  surface.  The  patient  should  be 
directed  to  breathe  through  his  mouth  during  the  applica- 
tion, and  to  avoid  swallowing  some  time  after,  so  as  to 
insure  the  dissolution  of  the  powders  in  situ.  Inhalations 
of  medicated  steam  are  very  useful  in  affections  of  the 
pharynx  and  tonsils.  The  inhaler  shown  in  Fig.  28,  the  low 
cost  of  which  places  it  within  the  reach  of  even  poor  pa- 
tients, may  be  used,  or  a  more  complicated  instrument, 
such  as  the  steam  atomizer,  represented  in  the  chapter  on 
"instruments  used  in  treating  diseases  of  the  .laryngeal 
cavity,"  which  projects  the  medicated  steam  through  the 
horizontal  glass  funnel  shown,  may  be  employed. 


CHAPTER  XVI. 

THEKAPEUTICS  OF  THE  PHARYNX. 

As  stated  in  Chapter  XV,  cleansing  of  the  pharynx  and 
the  adjacent  parts  prior  to  the  application  of  remedies, 
is  almost  as  important  as  in  the  nose.  It  enables  the 
medicament  to  come  in  direct  contact  with  tho  diseased 
surfaces,  this  being  further  assisted  by  drying  the  latter 
with  absorbent  cotton  immediately  before  each  application. 
If  these  precautions  are  neglected,  the  secretions  reduce  the 
strength  of  the  solution  used,  if  the  former  are  thin  and 
watery,  while  the  medicinal  agent  does  not  reach  the  part 
at  all  if  the  discharge  is  thick,  its  density  preventing  the 
contact  of  the  solution  and  all  action  upon  the  underlying 
membrane. 

Gargling  is  sometimes  effective  in  cleansing  the  posterior 
oral  cavity  of  superabundant  healthy  or  unhealthy  secre- 
tions; but  as  generally  practiced,  this  operation  is  very  in- 
effectual when  the  posterior  wall  of  the  pharynx  is  to  be 
reached.  As  usually  done,  a  mouthful  of  the  solution  used 
being  taken  into  the  mouth,  the  head  is  thrown  backward, 
and  the  fluid  gravitates  no  farther  than  the  soft  palate; 
this  adapts  itself  closely  to  the  base  of  the  tongue,  while 
a  current  of  air,  which  passes  through  a  slit  between  them, 
is  forced  through  the  liquid,  producing  the  gurgling  noise 
heard.  In  diseases  of  the  soft  palate  and  tonsils,  much 
benefit  sometimes  follows  this  popular  way  of  gargling, 
through  the  fact  that  the  latter  are  rotated  forward  while 
the  gargling  is  performed;  but  when  the  disease  implicates 
the  pharyngeal  wall,  the  latter  being  completely  closed  off, 
(248) 


THERAPEUTICS   OF  THE  PHARYNX.  249 

no  benefit  whatever  is  procured.  Properly  conducted,  garg- 
ling is  productive  of  excellent  results.  The  patient  having 
thrown  his  head  backward,  should  partially  swallow  the 
liquid,  i.e.,  arrest  it  just  as  the  act  is  to  be  completed,  and 
air  being  allowed  to  pass  through  it  (as  in  the  ordinary 
method)  for  a  few  seconds,  to  prevent  the  second  move- 
ment of  deglutition,  the  head  is  suddenly  tilted  forward, 
causing  the  fluid  to  regurgitate  into  the  mouth.  After  a 
few  trials  the  patient  will  generally  succeed  in  gargling 
effectively.  As  to  the  agents  to  be  employed  in  gargles, 
they  should  be  limited  to  those  which,  if  accidentally 
swallowed,  would  cause  no  deleterious  effects. 

The  cleansing  solutions  described  on  page  53  can  be  used 
for  the  pharyngeal  cavity  as  well  as  for  the  nose,  none  of 
them  possessing  sufficient  medicinal  activity  to  even  disturb 
the  stomach  in  the  one  dose.  The  bicarbonate  of  sodium 
arid  the  biborate  of  sodium  solutions  are  in  my  opinion 
more  effective  than  the  others.  ,  To  them  may  be  added 
chlorate  of  potassium  (3J-OJ)  which,  in  acute  troubles  espe- 
cially, is  invaluable. 

Medication. — The  agents  employed  in  the  treatment  of  the 
pharynx  do  not  differ  from  those  employed  in  the  nasal 
cavities.  The  reader  is  therefore  referred  to  the  chapter  on 
the  therapeutics  of  these  parts  for  their  enumeration  and  a 
detailed  account  of  their  properties. 


CHAPTEE  XVII. 

DISEASES   OF   THE   PHARYNX. 


ACUTE   PHARYNGITIS. 

(Synonyms:   Acute  Sore  Throat;    Acute   Catarrh  of  the  Pharynx; 
Angina  Catarrhalis.) 

Etiology. — Exposure  to  cold  or  damp  is  the  most  frequent 
cause  of  acute  pharyngitis,  especially  in  persons  in  whom 
in-door  life  and  sedentary  habits  have  diminished  the  resist- 
ing power  against  external  influences.  Rheumatism  and 
syphilis,  a  scrofulous  diathesis,  and  a  liability  to  herpetic 
eruptions,  predispose  to  it,  while  prolonged  treatment  with 
debilitating  agents  such  as  mercury,  iodide  of  potassium 
and  alkalies  in  general,  sqems  to  exert  some  influence  in 
rendering  the  pharynx  liable  to  the  disease.  It  may  occur 
as  a  complication  of  an  inflammatory  process  in  an  adjoin- 
ing part,  such  as  acute  rhinitis,  tonsillitis,  etc.  It  is  most 
frequent  in  young  people,  although  it  frequently  occurs  in 
old  age. 

Pathology. — The  brunt  of  the  inflammatory  process  is  not, 
as  usual,  evenly  distributed,  being  greater  in  some  parts  of 
the  membrane  than  in  others.  It  principally  involves  the 
glandular  structures,  their  action  being  interfered  with  by 
the  engorged  blood-vessels.  After  a  tiriie  the  glands  become 
over-stimulated  and  their  secretion  much  increased  and 
starchy,  this  process  retrograding  as  the  disease  disappears. 

Symptoms. — In  the  majority  of  cases  of  acute  pharyngitis, 
the  general  symptoms  are  so  slight  that  they  are  hardly 
perceived,  a  feeling  of  lassitude,  slight  headache,  and  super- 
(250) 


ACUTE   PHARYNGITIS.  251 

ficial  heat,  being  the  usual  train  of  sensations  experienced. 
The  local  symptoms  are  more  marked,  however.  At  first  a 
feeling  of  dryness  and  stiffness,  most  marked  when  degluti- 
tion is  performed,  is  noticed,  these  symptoms  increasing 
until  pain  becomes,  sometimes,  quite  severe.  As  a  rule 
the  voice  is  veiled,  and  a  feeling  as  if  a  foreign  body  were 
there  causes  the  patient  to  hawk  frequently.  After  a  few 
days  the  expectoration  increases,  a  thick  mucus  taking  the 
place  of  the  normal  secretion.  In  severe  cases,  the  sys- 
temic disturbance  is  much  greater;  a  chill  marks  the  onset 
of  the  attack,  and  high  temperature,  reaching  as  high  as 
103°  Fahr.,  is  present.  The  local  inflammation  being 
greater  in  proportion,  deglutition  is  very  painful,  and  all 
the  symptoms  are  proportionately  more  severe.  In  these 
cases,  extension  of  the  inflammation  to  the  laryngeal  cavity 
becomes  a  formidable  complication,  there  being  danger  of 
oedema  and  death.  The  cervical  glands  are  often  swollen 
and  painful  to  the  touch. 

Examination  of  the  pharynx  reveals  an  irregularly  dis- 
tributed redness,  or  patches  of  congestion  implicating,  in 
the  majority  of  cases,  the  posterior  pillars  and  the  posterior 
aspect  of  the  soft  palate.  Dilated  blood-vessels  may  be  seen 
coursing  over  the  inflamed  surfaces,  while  slight  elevations 
mark  the  seat  of  the  inflamed  follicles.  In  severe  cases,  the 
anterior  pillars,  the  uvula  and  the  tonsils  are  also  involved, 
the  redness  being  greater  and  more  evenly  distributed.  The 
tongue  is  generally  furred  when  the  affection  is  severe. 

Prognosis. — In  the  great  majority  of  cases,  the  affection 
lasts  but  six  or  seven  days,  but  it  usually  leaves  the  parts 
weakened  and  subject  to  renewed  attacks.  Death,  although 
occurring  exceedingly  rarely,  may  follow  a  very  severe 
attack  through  extension  of  the  inflammatory  process  to 
the  larynx. 


252  DISEASES    OF   THE   PHARYNX. 

Treatment. — The  introduction  of  cocaine  has  added  a  val- 
uable agent  to  our  list  of  remedies  for  the  treatment  of 
this  affection.  A  four  per  cent,  solution  applied  every  two 
hours  with  a  brush,  after  having  cleansed  the  parts  with 
chlorate  of  potassium  solution  and  dried  them,  has  several 
times  succeeded  in  cutting  an  attack  short  in  six  or  seven 
hours.  Wine  of  coca,  given  internally,  a  wineglassful  every 
two  hours,  also  assists  materially  in  hastening  resolution. 
Coca  lozenges,  each  containing  five  grains,  may  replace  the 
wine  when  the  latter  cannot  conveniently  be  taken.  These 
preparations  induce  contraction  of  the  vessels  of  the  mem- 
brane, thus  relieving  the  engorgement.  When  they  cannot 
be  procured,  the  next  best  remedy  is  perhaps  opium,  which 
also  stimulates  the  vaso-motors  when  taken  in  small  doses; 
three  to  five  drops  of  the  tincture  being  given  every  hour 
three  times,  then  every  two  hours.  Tincture  of  belladonna, 
two  drops  taken  in  the  same  manner,  can  be  administered 
instead  when  an  idiosyncrasy  prevents  the  use  of  opium. 
Guaiac  is  also  a  valuable  preparation,  internally  as  well  as 
locally,  especially  when  the  affection  occurs  in  a  rheumatic 
individual.  One  drachm  in  a  half  glassful  of  milk,  used  as 
a  gargle  and  swallowed  every  three  hours,  generally  succeeds 
in  arresting  an  attack  after  three  or  four  doses.  It  may 
also  be  administered  in  conjunction  with  steam,  a  drachm 
being  placed  in  a  teacupful  of  hot  water.  The  cup  being 
covered  with  a  towel  folded  into  a  cone,  the  mouth  is  placed 
over  the  upper  opening,  and  the  steam  is  inhaled  as  long  as 
it  is  generated.  The  inhaler  (Fig.  28)  may  be  used  with 
advantage. 

When  the  affection  is  due  to  hepatic  engorgement,  a  saline 
purgative  is,  of  course,  of  primary  importance,  followed  with 
phosphate  of  sodium,  a  teaspoonful  night  and  morning  for 
a  few  weeks,  which  acts  as  a  gentle  stimulant  to  the  liver. 


PLATE  vi. 


PLATE    VI. 

FIGURE  1. — Male,  stt.  12.'-);  acute  pharyngitis;  saline  purgatives ;  wine  of  coca;  two 
per  cent,  spray  of  cocaine. 

FIGURE  2. — Male  ;vt.  44;  simple  chronic  pharyngitis;  mild  purgation  every  other 
day.  using  podophyllin  ;  nitrate  of  silver  solution  (gr  lx-§j)  three  times  per  week,  alter- 
nating every  oilier  week  with  copper  sulphf  (gr.  x-§j)  solution.  Case  referred  by  Dr. 
Weaver,  of  Norristown. 

FIGURE  3. — Male,  ait.  21  ;  folliculous  pharyngitis;  galvano-cautery  to  follicles, 
followed  by  application  of  copper  sulph.  sol.  (gr.  v-§j) ;  attention  to  stomach  and  bowels. 
Case  referred  by  Professor  S.  W.  Gross. 

FIGURE  4. — Male,  «t.67;  atrophic  or  dry  pharyngitis;  nitrate  of  silver  sol.  (gr.  x-Jl) 
daily ;  oleo-resin  of  cubebs  internally. 

FIGURE  5, — Normal  appearance  of  pharynx,  uvula  and  palatal  folds — 

e,  Soft  palate.  o,  Posterior  pillar. 

/,  Uvula.  p,  Anterior  pillar. 

n,  Posterior  wall  of  pharynx. 

FIGURE  6. — Male,  -xt.  23;  tuberculosis  of  pharynx;  morphia  insufflations;  cocaine 
(not  known  at  that  time)  would  now  be  used.  Case  referred  by  Professor  William 
H.  Pancoast. 

FIGURE  7. — Male,  -xt  28 ;  retro- pharyngeal  abscess ;  abscess  opened.  Case  referred 
by  Dr.  L.  Webster  Fox. 

FIGURE  8. — Male,  jet  29;  syphilitic  ulceration  of  pharynx  and  soft  palate;  mercury 
and  iodide  of  potassium;  local  applications  of  iodoform  and  morphia;  afterwards 
cauterized  with  mitigated  stick. 

FIGURE  9. — Male,  set.  20 ;  adhesion  of  soft  palate  to  posterior  wall  of  pharynx, 
following  syphilitic  ulceration  ;  perforation  of  soft  palate,  enabling  patient  to  breathe 
through  the  nose. 


[NOTE  — Represented  as  seen  by  gas-light.     By  day-light,  the  red  color  appears  much  paler.] 


Plate     VI. 


C.£.  S  ajous,  Pin  x  // 


W.H.BUTLER  Ac? inn.  Pm  LA. 


SIMPLE   CHRONIC   PHARYNGITIS.  253 

SIMPLE   CHRONIC   PHARYNGITIS. 

(Synonyms: — Chronic    Catarrh    of  the  Throat;    Chronic  Sore  Throat; 

Relaxed  Throat.) 

Etiology. — Repeated  attacks  of  acute  pharyngitis  are  the 
most  prolific  factors  in  the  production  of  simple  chronic 
pharyngitis.  The  causes  of  the  former  are  therefore  those 
of  the  latter.  In  addition  to  these,  however,  may  be  added 
alcoholism  and  debauchery,  prolonged  exposure  to  dry  heat, 
the  constant  inhalation  of  smoke  and  inordinate  smoking,  a 
disturbed  state  of  the  digestive  apparatus,  and  hepatic  tor- 
pidity. Posterior  nasal  pharyngitis  is  also  a  frequent  cause, 
through  extension  of  the  inflammatory  process  from  above 
downward,  or  to  the  contact  of  the  secretions  which  descend 
from  the  diseased  surfaces. 

Pathology. — As  is  the  case  in  chronic  rhinitis,  frequent  in- 
flammatory manifestations,  whether  due  to  cold  or  to  other 
causes,  gradually  reduce  to  permanency  the  abnormal  con- 
dition of  the  vascular  supply  accompanying  an  acute  attack. 
Here,  however,  the  membrane  yields  to  the  expanding  action 
of  the  congestion,  and  after  frequent  repetition  of  the  in- 
flammatory process,  it  does  not  return  to  its  normal  position 
over  the  underlying  tissues,  but  remains  swollen,  falling 
back  in  folds.  When  an  acute  attack  (which  now  represents 
an  exacerbation  of  the  disease)  has  subsided,  the  glandular 
elements,  being  over-stimulated,  pour  out  an  excess  of  secre- 
tion, its  character  depending  upon  the  gravity  and  duration 
of  the  affection. 

Symptoms. — The  symptoms  of  the  affe'ction  are  more  than 
prone  to  manifest  themselves  by  exacerbations  than  as  con- 
tinued suffering.  Dryness  and  parchedness,  relieved  momen- 
tarily by  a  sip  of  water  or  other  beverage,  is  usually  the 
first  source  of  annoyance,  culminating  in  a  spicy  and  raw 


354  DISEASES   OF   THE   PHARYNX. 

sensation  extending  in  some  cases  to  the  vault.  The  voice 
is  usually  somewhat  hoarse  and  lowered  in  pitch,  and  is 
easily  tired.  Frequent  hacking  and  coughing  is  indulged  in 
to  clear  the  throat  of  accumulated  masses  of  thick,  tenacious 
mucus,  which  are  sometimes  tinged  with  pus  or  blood.  After 
a  few  days,  these  symptoms  become  somewhat  less  severe, 
a  stage  of  comparative  comfort  being  enjoyed  until  another 
slight  exposure  or  imprudence,  a  day's  constipation  or  an 
injudicious  meal,  bring  on  another  exacerbation. 

The  membrane  may  or  may  not  seem  congested,  but 
instead  of  the  smooth  appearance  of  health  and  the  sharply- 
defined  anterior  and  posterior  pillars,  the  membrane  appears 
as  if  formed  of  unevenly  distributed  folds,  and  presents  a 
granular  appearance.  The  posterior  pillars  are  sometimes 
thickened  sufficiently  to  cause  complete  obliteration  of  the 
recess  between  them  and  the  pharynx  proper.  The  uvula  is 
generally  implicated  and  elongated,  this  being  due  not  so 
much  to  the  disease  itself  as  to  the  constant  hacking  and 
scraping  indulged  in  to  clear  the  throat.  The  tonsils  are 
involved  in  the  majority  of  cases. 

Prognosis. — Although  in  no  way  dangerous  to  life,  chronic 
pharyngitis  is  persistent,  and  is  likely  to  become  aggravated 
unless  the  initial  causes  be  avoided,  and  an  uninterrupted 
and  prolonged  treatment  be  submitted  to. 

Treatment. — In  this  affection,  general  treatment  is  of  the 
utmost  importance.  In  the  majority  of  cases  hepatic  tor- 
pidity, evidenced  by  the  coated  tongue,  maintains  a  local 
congestion  of  the  pharynx,  and  attention  to  the  liver  will 
give  relief  when  all  local  measures  will  fail.  Podophylin, 
calomel  or  Hunyadi  water,  in  small,  but  often  repeated  doses, 
have  been  productive  of  best  results  in  my  hands.  Gastric 
disturbances,  when  present,  should  be  carefully  attended 
to,  while  abstinence  from  habits  which  tend  to  maintain 
the  trouble  should  be  enjoined. 


FOLLICULOUS   PHARYNGITIS.  255 

Of  the  local  remedies,  the  application  of  which  should 
always  be  preceded  by  careful  cleansing,  nitrate  of  silver, 
forty  grains  to  the  ounce,  is  in  my  opinion  the  most 
effective,  this  conclusion  having  been  reached  after  trying 
a  large  number  of  other  agents.  As  stated  in  the  chapter 
upon  therapeutics  of  the  nasal  cavities,  nitrate  of  silver 
causes  contraction  of  the  blood-vessels,  thus  diminishing 
the  local  congestion,  while  it  stimulates  the  absorbents  also, 
inducing  therefore,  absorption  of  the  inflammatory  products. 
Weak  solutions,  on  jthe  contrary,  of  ten,  fifteen,  or  even 
twenty  grains  to  the  ounce,  only  stimulate  the  superficial 
blood-vessels  and  increase  the  inflammatory  process.  Ap- 
plied once  daily  with  the  brush  (taking  care  to  not  take  up 
too  much  of  the  solution,  lest  it  run  into  the  larynx)  it  will 
in  a  very  short  time  produce  great  relief,  and  if  continued 
sufficiently  long  in  conjunction  with  the  internal  treatment, 
will  cure  the  affection.  Sulphate  of  copper,  ten  grains 
to  the  ounce,  applied  in  the  same  manner,  is  effective  in 
some  cases,  but  the  applications  must  be  continued  during 
a  long  period.  Occasionally,  cases  are  met  with  in  which 
astringents,  in  whatever  form  or  strength  they  may  be 
administered,  increase  the  inflammation.  Soothing  applica- 
tions are  therefore  indicated.  Vaseline,  rendered  liquid  by 
exposure  to  heat,  and  applied  with  the  brush  three  or  four 
times  daily,  is  generally  very  effective,  or  the  O  cosmoline, 
the  specific  gravity  of  which  is  sufficiently  low  to  enable  it 
to  be  used  in  the  atomizer,  may  be  employed. 

FOLLICULOUS   PHAKYNGITIS. 

(Synonyms  : — Follicular    Pha^-ngitis  ;    Granular   Pharyngitis  ;    Clergy- 
mans'  Sore  Throat;    Speakers'  Sore  Throat.) 

Etiology. — The^great  prevalence  of  this  affection  among 
persons  who,  in  their  avocations,  are  obliged  to  use  their 


256  DISEASES   OF   THE   PHARYNX. 

voice  extensively,  such  as  clergymen,  lawyers,  singers, 
hucksters,  etc.,  makes  it  evident  that  one  of  its  causes,  and 
probably  the  most  important,  is  extensive  use  of  the  vocal 
apparatus,  under  certain  unfavorable  conditions.  Whether 
this  be  due  to  an  inherent  liability  of  the  membrane  to  become 
influenced  in  that  manner  by  over  use  of  the  vocal  powers, 
or  to  some  defect  in  the  method  of  delivery,  is  difficult  to 
ascertain,  but  it  is  probable  that  both  play  an  important 
part  in  its  causation.  The  continued  oral  breathing  in  more 
or  less  dusty  atmospheres  doubtless  adds  greatly  to  these 
primary  causes.  Scrofulous  and  rheumatic  individuals  seem 
to  be  more  predisposed  to  it  than  others,  while  anemia  is 
a  frequent  accompaniment  in  marked  cases. 

The  affection  is  usually  seen  in  young  and  middle  aged 
people,  although  old  age  cannot  be  said  to  be  exempt.  It 
is  a  frequent  complication  of  chronic  affections  of  the  nose 
and  naso-pharynx,  the  contact  of  the  irritating  secretions 
being  most  probably  the  exciting  cause,  while  the  hacking 
and  coughing  accompanying  these  affections  tend  to  aggra- 
vate it.  The  inhalation  of  irritating  substances,  smoke  and 
dust,  are  also  frequent  causes. 

Pathology. — The  principal  pathological  conditions  charac- 
terizing this  affection  in  addition  to  the  vascular  engorge- 
ment and  tissue  changes  of  chronic  pharyngitis,  consists 
in  a  blocking  up.  as  it  were,  of  the  mouths  of  the  follicles. 
Their  products  accumulating  more  and  more,  each  follicle 
finally  becomes  metamorphosed  into  a  foreign  body,  which, 
becoming  encysted,  as  it  were,  remains  in  that  state  indefi- 
nitely, irritating  the  surrounding  parts.  How  this  condition 
is  brought  about  by  extensive  use  of  the  voice  seems  to  me 
explainable  :  the  follicles  are  overtaxed  by  the  unusually  great 
amount  of  lubrication  required,  and  this  being  frequently 
repeated,  an  inflammatory  process  is  gradually  induced. 


FOLLICULOUS   PHARYNGITIS.  257 

External  irritants  and  purulent  discharges  from  the  naso- 
pharynx cause  inflammation  of  the  mouths  of  the  follicles, 
•which  gradually  causes  their  closure. 

Symptoms. — The  onset  of  the  affection  is  usually  charac- 
terized by  an  occasional  sensation  of  dryness  in  the  pharynx 
and  larynx,  which  continues  for  a  short  time.  At  the  end 
of  a  few  days,  perhaps  after  a  prolonged  conversation,  the 
same  symptom  recurs,  to  follow  the  same  course  as  the 
preceding  attack.  This  is  repeated  several  times  at  vary- 
ing intervals,  each  attack  becoming  longer,  until  a  constant 
malaise  of  the  entire  throat  is  experienced,  which  in  time 
gradually  increases  in  intensity.  This  process  may  take  a 
few  weeks,  perhaps  a  few  months,  and  frequently  two  or 
three  years.  The  -voice  becomes  slightly  hoarse  upon  the 
least  exposure  or  exercise  in  speaking,  preaching,  or  sing- 
ing, and  if  the  exercise  is  continued  any  time,  a  sensation 
of  great  fatigue  in  the  parts  is  experienced.  A  short  hack- 
ing cough  is  usually  present,  accompanied  by  a  disposition 
to  clear  the  throat  frequently  and  to  expectorate.  When 
the  disease  has  progressed  for  some  time,  pain,  or  a  sensa- 
tion akin  to  it,  and  resembling  that  produced  by  the  pres- 
ence of  a  foreign  body,  a  pin,  a  fish  bone,  etc.,  is  com- 
plained of,  which  frequently  leads  the  patient  to  believe 
that  he  has  actually  swallowed  some  sharp  object.  In  some 
cases,  a  sensation  of  rawness  or  scratching  is  experienced, 
which  becomes  painful  when  deglutition  is  performed. 
Hawking,  expectorating  and  coughing  become  almost  per- 
manent in  bad  cases,  the  discharge  generally  consisting  of 
tough,  glairy  mucus,  contaminated  with  muco-purulent 
masses  or  scales,  if  a  nasal  affection  is  also  present.  The 
cough  is  provoked  by  a  tickling  sensation  in  the  larynx. 
The  voice  loses  its  timbre,  becoming  veiled  in  addition  to 
the  hoarseness;  these  symptoms,  however,  disappear  tern- 


DISEASES  OF  THE  PHARtNX. 

porarily  when  "  hemming"  is  practiced.  Elongation  of  the 
uvula  is  often  induced  by  the  hawking  and  the  continued 
congestion. 

Inspection  of  the  parts  reveals  the  striking  characteristic 
of  the  affection,  a  number,  more  or  less  great,  of  rounded 
projections,  reddish  in  color,  with  white  apices,  standing 
out  like  pimples,  from  the  surface  of  the  membrane.  A 
few  only  may  appear,  distributed  unevenly  over  the  entire 
mucous  surface,  including  the  pillars;  they  may  be  sepa- 
rated or  coalesced  into  clusters  of  three  or  four.  Enlarged 
vessels  are  generally  seen  coursing  between  them,  appearing 
in  some  cases  to  terminate  in  them,  or,  if  veins,  to  start 
from  them.  In  some  cases,  these  enlarged  follicles  burst 
and  discharge  a  thick,  cheese-like  substance,  which  escapes 
from  a  minute  opening  at  the  apex  of  the  growth.  At  times 
it  adheres  tenaciously  to  the  mouths  of  the  follicles,  forming 
small,  ill-smelling  patches  of  irregular  shape,  which  can  be 
peeled  off  without  difficulty.  This  exudative  form  (termed 
so  in  contradistinction  to  the  other  variety,  which  is  called 
the  hypertrophic  form)  of  the  affection,  is  most  frequently 
located  upon  the  anterior  and  posterior  pillars  and  the 
tonsils,  where  the  secretion  occasionally  assumes  a  calcareous 
character.  The  base  of  the  tongue  is  sometimes  implicated, 
its  glands  and  follicles  becoming  inflamed  and  hypertrophied. 

Prognosis. — Follicular  pharyngitis  can  generally  be  cured 
by  an  appropriate  treatment,  conducted  systematically  over 
a  prolonged  period.  Left  to  itself,  it  does  not  present  any 
danger  to  life,  but  it  may  encourage  the  development  of 
other  affections  of  the  larynx  and  naso-pharynx  through  the 
permanent  congestion  maintained. 

Treatment.— -The  treatment  of  this  form  of  pharyngitis  is 
essentially  surgical,  while  any  dyscrasia,  such  as  scrofula, 
syphilis,  rheumatism,  herpetism,  etc.,  should  be  treated  with 


FOLLICULOUS   PHARYNGITIS.  259 

appropriate  remedies.  The  state  of  the  digestive  apparatus 
should  be  carefully  inquired  into  and  appropriate  remedies 
administered.  The  liver  will  frequently  be  found  torpid, 
constipation  being  often  complained  of,  and  the  tongue 
showing  by  a  yellowish  fur  the  evidence  of  hepatic  engorge- 
ment. Mild  purgatives  are  always  advantageous  in  these 
cases,  followed  up  by  the  administration  of  phosphate  of 
sodium,  one  drachm  night  and  morning.  Cascara  sagrada  is 
an  excellent  aperient  in  these  cases,  from  fifteen  to  twenty 
drops  of  the  fluid  extract  being  taken  when  required. 

The  object  of  the  surgical  procedure  is,  both  in  the  hyper- 
trophic  and  exudative  forms,  to  destroy  each  enlarged  and 
engorged  follicle,  and  thereby  the  circuitous  inflammation 
which  its  presence  maintains.  This  may  be  done  by  means 
of  a  number  of  methods,  which  I  will  describe  in  the  order 
of  preference. 

Gralvano-cautery  has  by  far  given  the  best  results.  Besides 
being  a  painless  means,  it  gives  rise  to  no  disagreeable  after- 
symptoms  and  does  its  work  effectually.  A  small  loop 
twisted  at  the  tip  so  as  to  form  a  miniature  corkscrew,  is 
the  most  effective  instrument,  penetrating  deeply  into  the 
follicle  and  emptying  it  of  its  contents  when  withdrawn, 
while  not  creating  enough  local  disturbance  to  give  rise  to 
annoying  symptoms.  After  cleansing  the  pharyngeal  wall 
thoroughly,  each  engorged  follicle  should  be  touched  sepa- 
rately, six  or  seven  being  cauterized  at  each  sitting.  Hardly 
any  discomfort  is  caused  during  the  operation,  a  slight  sore 
throat,  lasting  a  couple  of  days,  representing  about  all  the 
after-effects.  A  few  days  later  the  cauterizations  are  re- 
newed, and  repeated  as  often  as  required.  I#  the  exudative 
form,  a  pair  of  long,  fine  forceps  should  previously  be  em- 
ployed to  dislodge  the  layer  of  cheesy  matter.  After  each 
sitting,  the  burnt  spots  present  a  white  appearance,  with  a 


2GO  DISEASES   OF   THE   PHARYNX. 

small  inflammatory  areola.  When  the  white  scab  disappears 
a  rod  spot  is  left,  which  in  turn  is  replaced  by  a  small  cica- 
trix.  The  relief  is  almost  immediate  and  is  lasting.  When 
the  superficial  vessels  are  large  and  present  evidences  of 
varicosity,  the  larger  ones  had  better  be  cauterized  in  the 
same  manner. 

Actual  cautery  is  also  very  efficient.  A  good-sized  sharp 
piece  of  wire,  mounted  upon  a  wooden  handle,  is  heated  to  a 
red  heat  in  the  fire  of  an  alcohol  lamp  and  applied  to  each 
follicle,  the  manipulation  being  conducted  and  repeated  as 
with  galvano-cautery.  The  fire  of  an  oil  lamp  or  gas  should 
not  be  employed,  the  carbonaceous  deposit  which  is  often 
formed  at  the  end  of  the  wire  retarding  greatly  the  resolu- 
tion of  the  burnt  follicle  if  accidentally  introduced  into  it. 

A  small  incision  into  each  follicle,  and  then  touching  the 
spot  with  solid  nitrate  of  silver  melted  on  the  end  of  a  probe, 
is  another  method  much  in  vogue  at  one  time,  but  which 
has  become  almost  obsolete  on  account  of  the  pain  occa- 
sioned and  the  somewhat  severe  after-effects.  Nitrate  of 
silver,  applied  without  incision,  is  effective  when  the  follicles 
are  seen  in  their  early  stage  of  formation,  i.e.,  w^hen  merely  a 
small  red  elevation  is  visible.  An  instrument  such  as  that 
used  for  actual  cautery  may  be  employed.  Its  tip,  being 
heated  over  an  alcohol  lamp,  is  applied  against  the  nitrate 
of  silver  crystal,  enough  of  which  will  adhere  for  two  or 
three  applications.  It  is  best,  however,  to  renew  the  coating 
of  silver  for  each  application.  The  resolution  of  the  parts  in 
this  method  of  treatment,  does  not  take  place  as  rapidly  as 
in  the  others  described,  and  more  time  should  elapse  between 
the  sittings.  Morell  Mackenzie  recommends  London  paste, 
preferring  this  agent  to  all  others.  The  preparation  being 
rubbed  up  with  sufficient  water  to  make  a  thick  cream,  is 
applied  to  two  or  three  follicles  at  each  sitting,  and  in  some 


MEMBRANOUS   PHARYNGITIS.  2G1 

cases  to  one  only.  The  patient  should  then  gargle  with 
cold  water,  to  remove  any  excess  of  the  caustic.  I  have 
found  this  method  more  troublesome  and  painful  than  the 
others,  without  increased  benefit. 

The  follicles  once  destroyed,  the  chronic  inflammation 
existing  in  the  membrane  proper  should  receive  attention. 
'The  local  treatment  recommended  in  chronic  pharyngitis  will 
be  found  as  advantageous  in  the  folliculous  variety. 

MEMBRANOUS   PHARYNGITIS. 

(Synonyms : — Membranous    Sore     Throat;    Aphthous     Sore    Throat; 
Croupous  Pharyngitis ;    Herpes  Pharj-ngis.) 

Etiology. — Membranous  pharyngitis  usually  occurs  in  per- 
sons of  weak  constitution.  Exposure  to  the  influences  of 
infectious  matter,  or  close  contact  with  persons  suffering 
from  septic  affections,  such  as  diphtheria,  scarlatina,  etc., 
are  among  the  frequent  causes  of  the  complaint,  while  cold 
may  also  excite  it  primarily,  especially  in  persons  who  have 
already  suffered  from  it. 

Pathology. — The  affection  consists  of  an  acute  superficial 
inflammation  of  the  mucous  membrane,  characterized  by 
the  exudation  of  a  whitish  substance  which  coagulates 
over  its  surface  in  the  form  of  thin  patches,  which  are  fre- 
quently mistaken  for  those  seen  in  diphtheria.  In  the 
latter  affection,  the  exudation  involves  the  entire  thickness 
of  the  membrane,  while  in  membranous  pharyngitis  it  is 
limited,  as  stated,  to  the  surface. 

Symptoms. — Membranous  pharyngitis  is  usually  ushered  in 
by  a  chill  or  creeping  sensations  in  the  back,  a  slight  head- 
ache and  soreness  in  the  throat.  Deglutition  soon  becomes 
painful,  and  a  thick  ropy  mucus  is  expectorated  witli  some 
difficulty.  The  tongue  is  usually  furred,  the  skin  is  hot, 
and  the  pulse  is  sometimes  quite  high. 


262  DISEASES   OF   THE   PHARYNX. 

Seen  in  the  first  stage  of  the  affection,  the  mucous  mem- 
brane of  the  pharynx  and  all  the  adjoining  parts  appears 
quite  red,  the  redness  being  still  greater  over  certain 
limited  areas  or  spots,  especially  around  the  tonsils.  After 
a  short  time  these  areas  become  covered  with  a  whitish  ex- 
udation, which  spreads  over  the  membrane  and  forms  patches. 
These  can  be  easily  detached  with  a  suitable  instrument,  dif- 
fering entirely  in  this  peculiarity  from  diphtheria,  in  which 
the  false  membrane  can  only  be  torn  away  with  great 
effort,  causing  sometimes  copious  hemorrhage.  The  appear- 
ance of  the  false  membranes  of  the  two  affections  differ 
also  in  a  marked  manner.  In  diphtheria  it  is  of  a  dirty 
yellow,  with  somewhat  everted  edges  and  surrounded  by  a 
dark-red  areola;  in  membranous  sore  throat,  the  exudation 
is  perfectly  white,  with  sometimes  a  tint  of  pink  or  gray. 
Its  surface  is  even,  and  the  areola,  if  any  exist,  is  hardly 
discernible. 

Prognosis. — The  prognosis  of  this  affection  is  favorable  in 
almost  every  case,  its  duration  being,  at  the  longest,  of  two 
weeks.  Extension  of  the  false  membrane  to  the  larynx, 
however,  may  cause  death  by  obstructing  mechanically  the 
passage  of  air;  but  such  an  accident  is  extremely  rare. 

Treatment. — A  mild  aperient  is  usually  indicated  in  these 
cases,  the  salines  being  preferable.  Pain  should  be  com- 
bated by  anodynes,  while  the  asthenic  nature  of  the  affec- 
tion should  be  antagonized  by  quinia  and  general  tonics. 
Wine  of  coca  is  exceedingly  valuable  in  this  affection,  a 

o    •/ 

wineglassful  every  two  hours  tending  greatly  to  diminish 
the  local  pain,  while  bracing  the  system.  Locally,  lime- 
water  used  with  the  atomizer  and  as  a  gargle,  can  be  employed 
with  advantage  to  keep  the  throat  clear  of  pseudo-mem- 
brane, which  necessitates  its  use  every  hour.  Chlorate  of 
potash  lozenges,  gr.  v  to  each  lozenge,  can  also  be  em- 


ATROPHIC   PHARYNGITIS.  263 

ployed.  A  plan  which  I  have  used  with  great  success, 
especially  in  children,  is  first  to  detach  the  false  mem- 
brane by  spraying  or  with  a  pledget  of  cotton,  then  to 
paint  the  underlying  mucous  membrane  with  a  ten-grain  solu- 
tion of  permanganate  of  potash  every  three  hours,  giving 
wine  of  coca  internally.  The  affection  is  generally  cut  short 
in  a  couple  of  days. 

ATROPHIC   PHARYNGITIS. 
(Synonyms  : — Pharyngitis  Sicca,  or  Dry  Pharyngitis.) 

Etiology. — Atrophic  pharyngitis  generally  occurs  as  a  sequel 
of  chronic  or  folliculous  pharyngitis,  or  as  a  result  of  continued 
exposure  to  dust,  smoke,  the  emanations  of  certain  irritating 
substances,  and  to  the  prolonged  contact  of  irritating  dis- 
charges from  the  posterior  nasal  cavity.  Sleeping  with  open 
mouth  is  also  an  occasional  cause.  Shurly,  of  Detroit,  as- 
cribes the  disease  to  organic  derangement  of  the  stomach  or 
allied  organs  in  most  cases.  In  old  people  it  frequently 
occurs  as  an  expression  of  the  general  senile  debility. 

Pathology. — The  principal  feature  of  this  affection  is  the 
state  of  inactivity  of  the  glands  and  follicles,  brought  on 
by  the  pressure  exerted  by  inflammatory  products  upon 
them,  and  through  which  the  mucus  necessary  to  keep  the 
parts  lubricated  is  not  generated.  Dryness  necessarily  ensues 
and  the  desiccated  condition  of  the  pharyngeal  surface  causes 
contraction,  which  in  turn  induces  pressure  upon  the  under- 
lying tissues.  These,  with  the  greater  part  of  the  vascular 
supply  and  glandular  elements,  are  absorbed,  reducing  the 
membrane  to  half  its  normal  thickness. 

Symptoms. — The  prominent  symptom  of  this  affection  is 
an  intense  dryness  of  the  pharynx,  extending  sometimes  to 
the  naso-pharynx.  A  sensation  of  stiffness  is  experienced, 


264  DISEASES   OF   THE   PHAEYXX. 

with  a  frequent  tendency  to  deglutition,  prompted  by  an 
unconscious  desire  to  lubricate  the  parts.  Eating  and  drink- 
ing is  generally  followed  by  momentary  relief,  while  de- 
glutition is  sometimes  performed  with  difficulty  through  the 
impaired  action  of  the  constrictor  muscles,  which  become 
rigid  and  stiff  in  the  affected  portions.  Swallowing  "the 
wrong  way"  is  a  frequent  accident  through  the  impaired 
action  of  the  epiglottis,  which  occasionally  takes  part  in 
the  inflammatory  process  and  the  impaired  sensitiveness  of 
the  pharynx.  A  dry  cough  is  occasionally  present  through 
implication  of  the  larynx. 

Upon  examination,  the  membrane  of  the  pharynx  appears 
perfectly  dry  and  lustrous,  with  perhaps  small,  muco-puru- 
lent  masses  adhering  to  its  surface  with  tenacity.  These 
may  originate  in  the  posterior  nares,  or  from  erosions  on 
the  surface  of  the  membrane,  caused  by  the  irritating  action 
of  foreign  particles,  which  remain  on  the  surface  through 
lack  of  secretion  to  wash  them  away.  The  outline  of  the 
bodies  of  the  underlying  vertebrae  can  generally  be  discerned 
when  the  disease  occurs  in  an  old  subject.  The  dryness 
can  frequently  be  seen  extending  to  the  posterior  nares 
and  the  larynx.  The  membrane  is  somewhat  paler  than 
normal. 

Prognosis. — In  young  people  the  affection  can  generally 
be  cured,  but  in  middle  aged  and  old  subjects,  temporary 
relief  only  can  be  furnished. 

Treatment. — The  first  indication  in  the  treatment  of  this 
affection  is  to  keep  the  membrane  free  of  discharges  by 
cleansing  it  as  frequently  as  possible,  while  the  liquid  em- 
ployed should  contain  an  agent  having  a  tendency  to  main- 
tain the  parts  in  a  moist  condition.  A  saturated  solution  of 
chlorate  of  potassium  is,  in  my  opinion,  the  best  solution  for 
the  purpose.  It  may  be  used  as  a  gargle  if  the  patient  can 


ATEOPHIC   PHARYNGITIS.  205 

gargle  properly,  or  it  may  be  used  with  an  atomizer,  in  both 
cases  as  frequently  as  possible.     Any  hurtful  habit  should  be 
corrected,  the  mouth  being  tied  up  at  night  if  necessary.    A 
slightly  stimulating  application  every  day  is  the  next  requisite, 
to   increase  the  nutrition  of  the  membrane  by  inducing  the 
formation  of  new  blood-vessels.      Too  stimulating  a  remedy 
should  be   avoided,  the   inflammation  resulting  being  more 
harmful  than  beneficial.     The  ten-grain  solution  of  nitrate  of 
silver  has  served  me  more  satisfactorily  than  any  other  agent 
for  the  purpose,  applied  with  a  cotton  pledget.     Iodine,  in  an 
equal  quantity  of  glycerine,  as  recommended  by  Fauvel,  of 
Paris,  is  also  an  efficient  remedy,  but  less  so  than  the  other. 
In  young   people    this    treatment,   when    carried  out  faith- 
fully, generally  gives  rise  to  favorable  results  in  from  one  to 
four  months.     In  persons  of  mature  age,  internal  treatment 
should  be  added,  to  stimulate  the  secretory  function  of  the 
mucous   membrane   or  that  of    the   salivary  glands.    Jabo- 
randi,    in    the    form    of    the    hydrochlorate    of    pilocarpine, 
gr.  &,  three  times  a  day,  is  perhaps  the  most  effective  remedy. 
Iodide  of  potassium,  gr.  iij,  and  chlorate  of  potassium,  gr.  v. 
are  sometimes  preferable,  especially  where  there  exists  some 
catarrhal   affection  of  the  nasal  cavities.     Fifteen   drops   of 
the  oleo-resin  of  cubebs  on  sugar,  is  another  agent  possess- 
ing much   merit.     Shurly  lays  much   stress    upon    general 
treatment  to  suit  the  systemic  disturbance  acting  as  cause. 
Galvanism  is  recommended  by  him,  the  positive  pole  being 
applied   to   the   pharynx.     Daily   sittings   are  necessary  for 
about   two   weeks,   after  which    they   can   gradually  be   di- 
minished.    Muriate  of  ammonia,  administered  in  tablets  con- 
taining gr.  iij  each,  is  advantageous  to  keep  the  pharyngeal 
wall   moist.     In   aged  people,  continued  local  treatment   is 
necessary  to  insure  comfort,  a  cure  being  doubtful,   if  at 
all  possible. 


CHAPTER  XVIII. 

DISEASES  OF  THE  PHARYNX — (Continued}. 

TU15EIICTJLOUS  PHARYNGITIS. 

(Synonyms: — Tuberculosis  of  the  Pharynx;    Consumption  of  the 

Pharynx.) 

Etiology. — Tuberculous  pharyngitis  generally  presents  itself 
as  a  complication,  either  of  tuberculosis  of  the  luiigs  or  the 
larynx,  or  of  both,  rarely  preceding  them.  Its  etiology  is  the 
same  as  that  of  tuberculosis  occurring  in  other  parts,  a  sub- 
ject which  will  be  treated  under  the  head  of  tuberculous 
laryngitis.  The  same  will  be  the  case  as  regards  the  pa- 
thology of  the  affection. 

Symptoms. — The  early  symptoms  of  a  case  of  tuberculous 
pharyngitis  are  generally  those  which  present  themselves 
in  the  early  history  of  acute  pharyngitis.  Deglutition 
becomes  very  painful,  especially  if  any  irritating  substances, 
such  as  strong  liquors,  vinegar  or  condiments  are  swallowed. 
As  the  disease  advances  these  symptoms  increase  in  in- 
tensity; the  pulse  becomes  rapid,  the  temperature  high,  and 
the  tongue  covered  with  a  whitish  fur.  Soon  after  the  begin- 
ning of  these  symptoms,  the  ulcerative  process  makes  its 
appearance.  A  shallow,  grayish  ulcer,  with  indistinct  out- 
line, presents  itself  on  the  pharyngeal  wall,  pillars,  or  soft 
palate  (most  frequently  the  latter  in  the  cases  seen  by  me), 
gradually  increasing  in  depth  and  giving  rise  to  a  slimy 
yellowish  discharge.  The  pain  becomes  continuous,  with 
exacerbations  when  swallowing;  it  is  of  a  sharp,  lancinating 
character,  and  frequently  extends  to  the  ear.  The  throat  is 
parched  and  dry.  The  ulcerative  process  extends  with  more 
(266) 


TUBERCULOUS   PHARYNGITIS.  2G7 

or  less  rapidity,  but  in  most  cases,  five  or  six  weeks  are 
sufficient  to  create  enough  local  disturbance  to  render  ali- 
mentation by  the  mouth  impracticable.  When  the  soft  palate 
is  greatly  ulcerated,  liquids  are  often  forced  into  the  nose. 

Prognosis. — The  prognosis  of  tuberculous  pharyngitis  is 
as  unfavorable  here  as  in  the  tuberculous  manifestations  in 
other  parts,  with  the  difference  that  on  the  whole  its  course 
is  more  rapid.  Six  months  represent  the  maximum  of  life 
in  the  cases  reported,  while  in  the  majority,  death  occurred 
in  from  six  to  ten  weeks  after  the  first  local  manifestation. 

Treatment. — Judging  from  its  effects  in  tuberculous  laryn- 
gitis, we  doubtless  have  in  cocaine  an  agent  of  the  greatest 
value  in  the  treatment  of  tuberculosis  of  the  pharynx.  The 
excruciating  pain  which  accompanies  it,  can,  with  a  ten  per 
cent,  solution,  be  kept  at  bay,  and  the  patient  receive  the 
benefit  of  an  amount  of  alimentation  which  the  suffering 
occasioned  by  deglutition  would  otherwise  cause  him  to 
refrain  from  taking.  It  should  be  applied  sufficiently  often 
to  prevent  all  pain,  after  cleansing  the  ulcerated  surface 
with  a  borax  spray  (gr.  v-!j).  Cauterizations  with  nitrate  of 
silver,  in  the  solid  form  or  solution,  have,  in  my  hands, 
proven  more  hurtful  than  beneficial.  I  have  obtained  more 
satisfactory  results,  as  far  as  contributing  to  the  patient's 
comfort  is  concerned,  by  sedative  applications.  Steam  inhala- 
tions, with  succus  conium,  a  dessertspoonful  in  a  half  pint  of 
water  at  130°  Fahr.,  or  inhaling  the  steam  of  hot  infusion  of 
belladonna,  hyoscyamus,  or  opium,  have  proven  very  valuable 
in  diminishing  pain  and  facilitating  deglutition.  Morphia, 
given  internally,  or  applied  locally,  gave  rise  to  so  much  dry- 
ness  of  the  parts  that  I  had  to  abandon  its  use. 

When  deglutition  becomes  impossible,  Bryson  Delavan's 
feeding  bottle,  described  later  on,  may  be  used  to  great  ad- 
vantage, or  the  patient  can  be  fed  by  the  rectum. 


2G8  DISEASES   OF   THE   PHARYNX. 

SYPHILITIC   PHARYNGITIS. 

(Synonyms : — Syphilis    of    the    Pharynx ;      Specific    Chronic    Pharyn- 
gitis ;    Syphilitic    Sore   Throat.) 

Etiology. — As  in  the  nasal  cavities,  syphilitic  manifesta- 
tions may  occur  as  a  result  of  direct  contamination  or  as  a 
symptom  of  the  secondary  or  tertiary  periods  of  syphilitic 
infection.  Primary  syphilis  in  this  location  is  more  fre- 
quently met  with  than  in  the  nose,  contact  with  an  infected 
subject,  in  kissing  or  biting,  using  table  utensils  or  glass, 
spoon  or  fork,  etc.,  improperly  cleansed  after  having  been 
used  by  a  syphilitic  individual,  and  certain  loathsome  prac- 
tices, rendering  the  pharyngeal  cavity  more  exposed  to  direct 
infection.  Secondary  syphilis  of  the  pharynx  is  met  with 
in  the  majority  of  cases  of  constitutional  syphilis,  the  pre- 
dilection of  this  region  to  become  affected  by  the  systemic 
dyscrasia,  being  probably  greater  than  any  other  portion 
of  the  system,  after  the  vulva  and  anus.  Tertiary  lesions 
are  of  frequent  occurrence,  and  may  present  themselves,  as 
in  the  nasal  cavity,  as  long  as  thirty  years  after  the  primary 
infection,  although  six  or  seven  years  represent  about  the 
interval  between  the  primary  and  tertiary  manifestations. 
Syphilitic  pharyngitis  may  also  be  hereditary. 

Pathology. — The  remarks  on  the  general  pathological  mani- 
festations of  syphilis  occurring  in  the  mucous  membrane 
made  under  the  heading  of  syphilitic  rhinitis,  are  also  appli- 
cable to  syphilitic  manifestations  of  the  pharynx. 

Symptoms.— The  symptoms  of  syphilitic  pharyngitis  vary 
according  to  the  stage  of  the  disease.  In  primary  syphilis, 
the  subjective  symptoms  are  usually  so  slight  as  to  be  over- 
looked at  first.  After  a  few  days  the  glands  under  the 
angle  of  the  lower  jaw  become  painful  to  the  touch,  and 
examination  of  the  throat  reveals  one  or  more  reddish 


SYPHILITIC   PHARYNGITIS.    '  2G9 

or  whitish  abrasions,  with  slightly  elevated  edges.  These 
almost  always  heal  spontaneously,  but  they  may,  as  was 
the  case  in  Diday's  patient,  be  followed  by  phagedsenic 
ulceration.  Their  differentiation  from  tuberculous  uleera- 
tion  is  somewhat  difficult. 

Secondary  lesions  may  present  themselves  in  two  forms, 
as  an  erythema,  and  in  the  form  of  mucous  patches.  They  are 
apt  to  be  located  symmetrically,  on  both  sides  of  the  pharyn- 
geal  cavity.  Erythema  usually  begins  by  a  diffuse  redness 
of  either  the  entire  cavity  or  only  a  portion  thereof.  The 
symptoms  of  an  ordinary  sore  throat  are  then  experienced, 
with  dryness  and  pain,  and  sometimes  slight  pyrexia.  After 
a  few  days,  sometimes  only  twenty-four  hours,  clearly  out- 
lined patches  show  themselves,  located  on  the  tonsils  and 
anterior  pillars,  the  pharyngeal  wall,  or  the  soft  palate,  and 
coalescing  at  times  so  as  to  form  an  almost  continuous  chain 
of  blotches,  which  present  in  color  the  ordinary  aspect  of 
catarrhal  inflammation.  The  larynx  generally  becomes  in- 
volved, cough  and  hoarseness  being  added  to  the  other 
symptoms.  Mucous  patches  generally  make  their  appear- 
ance upon  the  anterior  pillars  and  the  soft  palate ;  they  may 
be  found,  however,  in  any  other  portion  of  the  pharyngeal 
and  oral  cavities,  the  sides  of  the  tongue  being  a  favorite 
site  for  them.  At  first  they  appear  as  mere  circumscribed, 
regularly  defined,  oval  elevations,  which  soon  become  dark 
red,  then  slightly  excavated,  afterwards  changing  in  color 
to  a  whitish  gray.  The  subjective  symptoms  are  more 
accentuated  than  when  erythematous  patches  are  present, 
the  dysphagia  especially  being  greater. 

Tertiary  manifestations  do  not  present  the  same  degree 
of  symmetry  as  those  of  the  second  period.  The  soft  palate 
and  one  of  the  tonsils  are  generally  the  first  invaded,  the 
ulcerative  process  spreading  rapidly.  In  almost  every  case, 


270  DISEASES   OF   THE   PHAHYNX. 

the  first  local  trouble  is  the  formation  in  the  layers  of 
the  membrane,  of  one  or  more  gummous  tumors,  which 
form  small  nodular  swellings ;  these  may  remain  inactive 
for  some  time,  or  proceed  at  once  to  soften,  suppurate,  and 
give  rise  to  a  deep-seated  ulceration.  The  ulcer  formed 
is  cup-shaped,  with  an  irregular,  sharply  cut  and  jagged 
edge,  and  covered  by  an  ichorous  yellowish  discharge.  When 
situated  in  the  soft  palate,  it  is  quite  likely  to  cause  perfora- 
tion. Located  on  the  posterior  wall  of  the  pharynx,  adhe- 
sion of  the  soft  palate  is  liable  to  take  place,  the  parts  heal- 
ing together.  The  ulcerative  process  may  create  great  havoc 
in  all  the  parts,  the  cicatricial  contraction  which  generally 
follows  often  limiting  the  isthmus  markedly,  and  sometimes 
closing  it  up  altogether,  as  was  the  case  in  a  subject  under 
my  observation.  The  subjective  symptoms  are  not  com- 
mensurate with  the  degree. of  local  mischief,  although  some- 
times great  pain  is  experienced;  deglutition  is  always  diffi- 
cult and  in  some  cases  liquids  can  alone  be  swallowed ;  slight 
cough  is  usually  present,  due  to  involvement  of  the  larynx 
in  the  general  congestion.  The  tumefaction  of  the  soft 
palate  prevents  its  apposition  against  the  wall  of  the  pharynx, 
and  the  voice  acquires  the  nasal  twang. 

Prognosis. — The  prognosis  of  syphilitic  pharyngitis  as  re- 
gards life,  can  only  be  unfavorable  when  the  disease  occurs 
as  a  manifestation  of  tertiary  syphilis.  The  liability  of  the 
ulcerative  process  to  penetrate  deeply  into  the  tissues,  mena- 
cing bones,  cartilage,  and  blood-vessels,  creates  dangers  which, 
although  seldom  realized,  are  nevertheless  to  be  feared,  and 
thwarted  if  possible.  In  debilitated  persons,  and  in  those  in 
whom  the  disease  has  existed  in  its  active  form  for  a  long 
time,  death  may  take  place  by  exhaustion. 

Treatment. — The  constitutional  treatment  recommended  in 
syphilitic  rhinitis  is  as  valuable  in  syphilis  of  the  pharynx, 


SYPHILITIC   PHAEYNGITIS.  271 

and  often  suffices  to  induce  prompt  recovery.  Local  cleans- 
ing is  of  the  greatest  importance,  and  should  be  practiced 
several  times  in  either  of  the  three  stages  of  the  disease.  I 
have  used  with  much  success  in  these  cases,  the  permanga- 
nate of  potash  solution  described  on  page  118.  It  is  not  only 
an  effective  detergent,  but  the  slight  stimulation  which  it 
produces  tends  to  hasten  resolution.  Besides  these  qualities, 
it  is  an  excellent  disinfectant  and  soon  changes  the  character 
of  the  secretions.  In  the  primary  stage,  but  little  if  any  other 
local  medication  is  necessary ;  a  weak  astringent  such  as  a 
five  grain  solution  of  sulphate  of  zinc  or  acetate  of  lead  may 
be  used  to  perhaps  hasten  the  recovery,  which  almost  always 
occurs  spontaneously  in  a  week  or  so.  In  secondary  symp- 
toms, a  solution  of  nitrate  of  silver  (gr.  xxx-sj)  has  given  me 
the  greatest  satisfaction,  applied  with  a  camel's  hair  pencil 
to  each  blotch  after  thorough  cleansing.  lodoform  is  also 
very  useful,  but  its  unpleasant  odor  renders  it  very  ob- 
jectionable to  the  patient.  Tincture  of  the  chloride  of  iron, 
fifteen  minims  in  a  drachm  of  glycerine,  is  also  very  effi- 
cient, painted  over  the  mucous  patches  three  times  daily. 
In  the  tertiary  form,  the  mitigated  stick  (composed  of  one 
part  of  oxide  of  silver  and  nine  of  nitrate  of  silver)  is, 
in  my  opinion,  more  effective  than  any  other  application. 
It  should  be  applied  carefully  to  the  ulcerations  and  some 
distance  around  the  margin,  after  careful  spraying.  Acid 
nitrate  of  mercury  is  another  valuable  remedy,  used  in  the 
same  manner.  lodoform  can  also  be  used  with  good  effect. 
Powdered  astringents  such  as  alum,  tannin,  etc.,  can  be 
used  with  benefit  by  insufflators,  their  constringing  action 
upon  the  blood-vessels  decreasing  the  intensity  of  the  in- 
flammation. 


CHAPTER  XIX. 

DISEASES    OF   THE   PHARYNX — (Continued). 
RETRO- PHARYJsGEAL   ABSCESS. 

Etiology. — The  formation  of  an  abscess  in  the  posterior 
wall  of  the  pharynx  may  occur  as  a  complication  of  acute 
pharyngitis,  or  be  due  to  inflammation  of  the  connective 
tissue  and  lymphatic  glands  between  the  pharyngeal  walls 
and  the  vertebrae,  or  of  the  latter  themselves.  It  is  most 
frequent  in  the  early  months  of  life,  although  it  may  occur 
at  any  age.  Scrofula  and  syphilis  are  predisposing  causes 
of  the  idiopathic  abscess,  which  is  the  most  common  form. 
It  occasionally  follows  scarlatina,  erysipelas,  diphtheria,  and 
other  exanthemata.  It  is  often  caused  by  traumatism,  falls 
against  some  sharp  instrument  which  penetrates  the  opened 
mouth,  swallowing  spicules  of  bone,  etc.  Necrosis  of  the 
vertebrae  is  a  frequent  cause  of  retro-pharyngeal  abscess. 

Symptoms. — The  early  symptoms  of  the  formation  of  a 
retro-pharyngeal  abscess  are  but  seldom  characterized  by 
systemic  disturbance.  A  slight  chill  or  occasional  chilly 
sensations  may  be  experienced,  with  some  headache.  The 
local  symptoms  are  usually  those  which  first  attract  atten- 
tion, and  these  vary  according  to  the  location  of  the  abscess. 
It  may  be  located  sufficiently  high  and  be  hidden  behind  the 
soft  palate,  and  require  the  rhinoscope  to  ascertain  its  out- 
line ;  it  may  be  situated  opposite  the  larynx,  and  only  be 
seen  in  its  entirety  with  the  laryngoscope;  again,  it  may  be 
located  on  the  side,  behind  the  posterior  pillar.  In  the 
majority  of  cases,  however,  its  situation  is  in  the  posterior 
wall  of  the  pharynx,  facing  the  oral  cavity,  and  on  either 
(272) 


EETEO-PKARYNGEAL   ABSCESS.  273 

side  of  the  median  line.  When  the  abscess  is  situated  high 
up,  a  sensation  as  if  a  foreign  body  were  located  in  the 
vault  is  experienced,  accompanied  by  difficult  deglutition 
and  some  interference  with  the  respiration  through  the  nose. 
Pain  of  a  dull,  throbbing  character,  but  occasionally  very 
sharp  and  lancinating,  may  be  felt,  accompanied  by  head- 
ache and  tinnitus.  The  speech  becomes  nasal  and  devoid 
of  resonance,  the  consonants  being  accompanied  by  a  sound 
of  "  escaped  air"  through  the  nose.  When  opposite  the 
larynx,  dyspnoea  is  a  marked  symptom,  coming  on  in 
spasmodic  attacks  which  endanger  the  patient's  life ;  swal- 
lowing becomes  very  difficult  and  dangerous,  owing  to  the 
occasional  passage  of  food  into  the  larynx,  and  this  is  likely 
to  occur  frequently  unless  great  care  be  taken.  This  danger 
is  further  increased  by  the  interference  presented  by  the 
bulging  surface  to  the  free  motion  of  the  epiglottis.  When 
the  abscess  is  in  the  posterior  wall  of  the  pharynx,  respira- 
tion is  not  interfered  with  until  it  has  attained  great  size. 
In  addition  to  the  local  symptoms,  there  is  swelling  of  the 
neck  on  the  side  of  the  tumor,  and  the  cervical  glands  may 
be  enlarged  and  painful.  The  head  is  drawn  to  one  side 
or  forward  in  some  cases,  and  can  only  be  raised  with  great 
difficulty.  As  the  formation  of  pus  proceeds,  fever  and 
pyrexia  are  generally  present,  the  pulse  being  weak  and 
easily  compressed.  Left  to  itself,  the  abscess  generally 
bursts  spontaneously,  a  mass  of  pus  being  suddenly  evacu- 
ated into  the  mouth  or  throat,  sufficiently  great  sometimes, 
to  asphyxiate  the  patient.  At  times  the  pus  burrows  under 
the  tissues  and  forms  an  opening  at  some  remote  point.  If 
near  the  larynx,  oedema  may  be  caused  by  penetration  of 
the  suppuration  into  the  ary-epiglottic  fold. 

The   tongue   being  depressed,  a   tumid   swelling,   red   and 
dusky  in  color,  is  seen  to  project  into  the  pharyngeal  cavity, 

is 


274  DISEASES   OF   THE   PHARYNX. 

the  view  being  more  or  less  complete  according  to  its 
location.  The  surrounding  parts,  the  pillars  and  uvula,  are 
usually  inflamed  and  swollen,  especially  on  the  side  of  the 
abscess.  With  the  finger,  fluctuation  can  generally  be  felt 
almost  from  the  start,  although  weeks  are  sometimes  passed 
before  the  accumulation  of  pus  is  sufficiently  great  to  cause 
rupture. 

The  symptoms  of  retro-pharyngeal  abscess  resemble,  in 
some  particulars  those  of  croup.  Cough,  however,  is  absent, 
a  marked  feature  of  the  latter  disease,  while  the  voice  is  rarely 
affected.  Again,  it  is  often  confounded  with  and  treated  for 
acute  tonsillitis.  (Edema  of  the  larynx  has  also  been  mis- 
taken for  it  in  the  adult.  The  propriety  of  always  examining 
the  throat  carefully  in  croup  and  other  diseases  in  which  the 
lanrnx  and  pharynx  are  implicated,  is  here  well  exemplified, 
the  life  of  the  patient  depending  greatly  upon  a  proper  recog- 
nition of  the  trouble. 

Prognosis. — When  the  abscess  is  caused  by  caries  of  the 
vertebra?,  the  prognosis  is  unfavorable,  death  taking  place 
in  the  majority  of  cases.  In  the  other  forms  of  abscess,  it 
is  rarely  fatal  except  by  accidental  causes,  such  as  asphyxia 
by  the  sudden  escape  of  pus  into  the  larynx,  etc. 

Treatment. — The  only  treatment  is  the  evacuation  of  the 
contents  of  the  abscess  by  an  incision  with  a  bistoury  or  by 
withdrawing  the  fluid  by  means  of  a  trocar  and  aspirator. 
When  the  former  means  is  employed  a  small  vertical  in- 
cision high  up  (as  recommended  by  Dr.  MacCoy,  of  Phila- 
delphia), and  not  at  the  point  of  greatest  tensio.ii,  avoids  the 
danger  of  suffocation  by  the  sudden  flow  of  a  large  quantity 
of  pus  which  a  free  incision  would  occasion.  After  the  ten- 
sion of  the  abscess  has  been  relieved,  the  incision  can  be 
somewhat  extended,  but  only  to  a  limited  extent,  lest  par- 
ticles of  food  penetrate  into  it  during  the  act  of  deglutition. 


TUMORS    OF   THE   PHARYNX.  275 

The  abscess  can  be  emptied  gradually  by  digital  compres- 
sion, the  pus  being  worked  out  by  gently  sliding  the  finger 
upwards  over  it,  so  as  to  bring  the  fluid  to  the  level  of  the 
incision.  The  discharge  continues  for  some  time,  the  cavity 
growing  smaller  and  smaller  until  the  wound  is  healed. 

In  using  the  aspirator,  a  straight  trocar  pushed  in  at  right 
angles  with  the  growth  is  liable  to  wound  the  posterior  wall 
of  the  abscess,  or  to  pierce  the  vertebrae,  an  accident  which 
may  take  place  in  the  most  careful  hands,  owing  to  the 
resistance  which  is  sometimes  offered  to  the  penetration 
of  the  trocar  point,  and  the  suddenness  with  which  it  enters 
the  cavity  of  the  abscess.  A  trocar  shaped  like  that  shown 
in  the  cut,  can  be  introduced  from  below,  and  the  operation 


Retro-pharyngeal  abscess  trocar. 

can  be  performed  without  the  least  danger,  while  a  ten  per 
cent,  solution  of  cocaine  applied  freely  over  the  abscess  and 
the  surrounding  parts  will  prevent  all  pain. 

» 

TUMORS    OF   THE   PHARYNX. 

Although  tumors  in  the  pharyngeal  cavity  are  rarely  met 
with,  almost  every  variety  of  growth  may  be  found  there. 
Cases  of  sarcoma,  fibro-sarcoma,  fibroma,  osteoma,  enchon- 
droma,  adenoma,  papilloma,  cysts  and  lupus,  have  been 
reported.  These  growths  may  originate  in  the  pharynx 
proper,  or  penetrate  into  it  from  the  surrounding  parts. 
Their  most  frequent  location  is  on  the  lateral  walls,  involv- 
ing the  palatine  folds,  and  extending  to  the  surrounding 


1276  DISEASES    OF    THE   PHARYNX. 

parts.  They  present  the  same  properties,  in  shape,  den- 
sity and  color,  as  in  the  nose.  Aneurism  of  the  internal 
carotid  artery  has  also  been  seen  in  this  location,  a  globular 
mass  protruding  into  the  pharyngeal  cavity. 

Symptoms. — The  presence  of  pharyngeal  tumors  is  usually 
not  recognized  until  they  have  attained  sufficient  size  to  in- 
terfere with  deglutition  or  with  respiration.  As  in  retro- 
pharyngeal  abscess,  the  symptoms  vary  according  to  the 
location  of  the  growth.  Outside  of  carcinoma  and  lupus, 
which  are  ulcerative  and  very  painful,  and  gradually  spread 
to  the  surrounding  parts,  all  the  other  varieties  named  are 
characterized  by  obstruction  to  both  deglutition  and  respira- 
tion, pain  being  usually  very  slight.  Pharyngeal  tumors 
may  bo  mistaken  for  retro-pharyngeal  abscess  or  hypertro- 
phied  tonsils.  Palpation,  however,  in  connection  with  a 
careful  examination,  will  serve  to  establish  the  true  diag- 
nosis. 

Treatment. — The  treatment  consists  in  extirpation,  when 
practicable.  This  may  be  done  by  means  of  the  knife,  the 
snare  or  galvano-cautery.  Electrolysis  may  also  be  em- 
ployed, especially  when  the  tumor  is  not  of  hard  consist- 
ence. 

PARALYSIS    OF   THE    PHARYNX. 

Etiology. — Paralysis  of  the  pharynx,  which  implies  paralysis 
of  its  muscles,  may  occur  as  a  result  of  general  disease  with 
local  expression,  such  as  diphtheria,  or  syphilis,  or  be  due 
to  a  cerebral  affection  implicating  the  nerves  which  supply 
the  pharynx.  The  paralysis  may  be  limited  to  one  con- 
strictor muscle,  or  involve  them  all ;  it  may  involve  one 
side  of  the  pharynx  or  both,  and  if  the  latter  be  the  case,  it 
is  generally  more  marked  on  one  side  than  on  the  other.  It 
is  an  occasional  complication  of  hemiplegia,  being  limited  to 


FOREIGN    BODIES   IN    THE   PHARYNX.  2<7 

the  same  side.  It  frequently  occurs  as  a  precursor  of  death 
in  febrile  diseases. 

Symptoms. — The  most  marked  symptom  is  the  difficulty 
of  deglutition,  the  greatest  efforts  being  required  to  force 
the  food  down  the  oesophagus.  Liquids  are  generally  swal- 
lowed with  less  difficulty,  but  their  frequent  passage  into 
the  larynx,  especially  when  the  epiglottis  is  also  paralyzed, 
renders  their  use  dangerous.  When  the  soft  palate  is  in- 
volved, the  food  may  be  forced  into  the  posterior  nasal 
cavity,  through  the  efforts  of  the  tongue  to  assist  deglutition. 

Treatment. — The  central  causes  should  be  carefully  sought 
for  and  treated.  Strychnine  hypodermically  and  general 
tonics  are  almost  always  indicated.  Arsenic  is  especially 
valuable  when  the  affection  is  a  sequel  to  diphtheria.  Elec- 
tricity serves  the  double  purpose  of  assisting  in  the  diagnosis 
and  restoring  motion.  When  the  paralysis  is  of  central 
origin,  an  interrupted  current  will  cause  contraction  of  the 
muscles,  but  this  contraction  will  not  occur  if  atrophy  of 
the  muscles  is  the  principal  pathological  element  of  the 
case ;  the  cure  will  then  be  rendered  much  more  difficult,  if  at 
all  possible.  Therapeutically,  electricity  should  be  applied 
with  both  electrodes  over  the  muscles  for  about  ten  minutes 
every  other  day. 

FOREIGN  BODIES  IN  THE  PHARYNX. 

The  two  classes  of  objects  which  are  most  frequently 
found  in  the  pharynx,  are,  firstly,  those  presenting  sharp 
points  or  asperities,  such  as  needles,  pins,  tacks,  fish-bones, 
fragments  of  meat,  bone,  bristles,  etc.,  which  the  contractions 
of  the  constrictors  in  deglutition  force  into  the  pharyngeal 
walls,  and,  secondly,  those  whose  dimensions  do  not  allow 
their  passage  into  the  oesophagus,  such  as  pieces  of  meat, 
bread  crust,  false  teeth,  coins,  etc. 


278  DISEASES   OF   THE   PHAHYNX. 

Symptoms. — Objects  which  are  long  and  narrow,  such  as 
pins,  needles,  fish-bones  and  bristles,  are  generally  caught 
transversely,  and  are  found  sticking  into  the  sides  of  the 
pharynx  in  almost  every  case,  at  times  as  high  up  as  the 
tonsils ;  tacks,  being  of  small  size,  are  rarely  caught  by  the 
constrictors,'  this  being  only  possible  providing  its  long 
axis  be  aiitero-posterior,  while  passing  behind  the  larynx. 
As  a  general  thing  they  do  not  reach  as  far  as  that  region, 
but  fall  on  either  side  of  the  epiglottis  into  the  pyriform 
sinus,  where  they  are  generally  found.  Bodies  which  are 
arrested  on  account  of  their  size,  are  usually  found  either 
behind  the  larynx  or  above  it,  and  resting  upon  the  epi- 
glottis, which  they  sometimes  hold  down.  Small  objects, 
such  as  buttons,  pebbles,  etc.,  generally  slip  into  the  glosso- 
epiglottic  fossa3  or  into  the  pyriform  sinuses. 

The  symptoms  vary  greatly  according  to  the  nature  of 
the  foreign  body.  When  a  small,  sharp  object  is  impacted 
in  the  pharynx,  the  sticking  sensation  which  it  gives  rise  to 
is  markedly  increased  by  deglutition;  or,  it  may  be  felt  in 
two  places  at  once,  the  latter  being  often  the  case  when 
a  needle,  for  instance,  is  swallowed.  Large  bodies,  by 
holding  the  epiglottis  on  the  larynx,  may  cause  death 
before  assistance  can  be  obtained.  Lodged  in  one  of  the 
pyriform  sinuses  they  do  not  give  rise  to  as  much,  dis- 
comfort as  in  other  locations,  and  may  remain  there  for  a 
long  time  without  interfering  with  the  functions  of  the 
surrounding  parts. 

Localized  spots  of  irritation,  such  as  inflamed  follicles, 
when  situated  low  down  on  the  pharyngeal  wall,  frequently 
give  rise  to  the  sensation  produced  by  a  foreign  body.  This 
sensation  may  also  be  caused  by  a  piece  of  bone  or  a  crust 
of  bread,  which,  when  swallowred,  scratches  the  membrane, 
leaving  an  abraded  spot.  Again,  a  foreign  body  may  have 


FOREIGN   BODIES   IN   THE   PHARYNX.  279 

become  impacted,  then  swallowed  or  ejected,  and  the  patient 
still  continue  to  experience  the  sensation  that  it  gave  rise 
to  before  being  ejected.  These  facts,  to  which  may  be  added 
the  imaginary  foreign  body  of  hysterical  women,  are  of  im- 
portance, and  should  be  remembered  when  measures  to  ex- 
tract it  are  to  be  resorted  to. 

Prognosis. — Sharp  objects,  by  being  forced  into  one  of  the 
large  arteries  of  the  neck,  may  cause  death  by  hemorrhage, 
while,  as  we  have  seen,  asphyxia  may  be  caused  by  a  large 
foreign  body.  In  the  great  majority  of  cases,  however,  the 
object  can  be  withdrawn  without  trouble,  the  patient  re- 
covering very  soon. 

Treatment. — The  laryngeal  mirror  is  of  great  assistance  in 
ascertaining  the  position  of  the  impacted  body.  The  nature, 
shape  and  density  of  the  object  swallowed  being  ascer- 
tained, it  may  be  looked  for  in  the  portion  of  the  pharynx, 
in  which,  as  explained  above,  it  is  most  likely  to  become 
located.  A  satisfactory  examination  of  the  parts  is  not 
always  obtainable,  however,  owing  to  the  marked  conges- 
tion generally  present  and  the  quantity  of  saliva  secreted. 
The  index  finger  can  then  be  used  to  advantage,  by  pass- 
ing it  into  the  pharynx  and  examining  each  part  as  it  is 
reached;  the  right  finger  should  be  used  for  the  right  side 
of  the  throat,  and  the  left  for  the  left  side,  so  as  to  always 
have  its  palmar  surface  against  the  membrane.  The  finger 
may  not  only  be  used  for  the  exploration,  but  also  to  grasp 
the  foreign  body  and  withdraw  it.  The  recess  between  the 
nail  and  finger  is  well  adapted  for  the  entrance  of  the  shaft 
of  a  pin,  for  instance,  and  once  in  position  can  be  held 
firmly  by  resting  the  palmar  side  of  the  finger  against  the 
nearest  surface  while  drawing  it  out,  the  pin  being  thus 
held  tightly  in  its  position.  When  the  object  is  too  large 
to  be  grasped  in  this  manner,  the  finger  should  be  held  on 


280  DISEASES   OF   THE   PHARYNX. 

the  foreign  body  until  a  pair  of  forceps,  introduced  by  slip- 
ping them  along  the  finger  can  be  fastened  on  to  it.  The 
most  convenient  instrument  for  the  purpose  is  Seller's  tube 
forceps  shown  in  Fig.  69.  The  flexible  tube  shaft  can  be 
conveniently  adjusted  to  any  suitable  shape,  thus  facilitating 
its  introduction  in  any  part  of  the  pharyngeal  cavity. 

When,  through  the  presence  of  a  large  foreign  body,  the 
patient's  death  appears  imminent,  tracheotomy  must  be  per- 
formed at  once,  or  if  the  necessary  instruments  are  not  at 
hand,  the  trachea  can  be  opened  with  a  penknife,  and  main- 
tained so  until  the  foreign  body  can  be  withdrawn.  This 
extreme  measure,  however,  is  rarely  necessary,  and  there  is 


Seller's  tube  forceps i 

usually  sufficient  time  to  pass  the  finger  in   the  throat  and 
extract  the  offending  object. 

After  a  foreign  body  has  been  extracted,  there  remains  for 
a  time  a  sensation  as  if  it  were  yet  there,  and  it  is  some- 
times difficult  to  persuade  the  patient  that  there  is  not  an- 
other foreign  body  in  his  throat.  This  might  possibly  be 
the  case,  however,  and  a  careful  examination  should  always 
be  made. 


CHAPTER   XX. 

DISEASES   OF   THE   TONSILS   AND   UVULA. 
TONSILLITIS. 

(Synonyms:  —  Quinsy;    Amygdalitis  ;    Cynanche   Tonsillnris  ;     Angina 
Tonsillaris;    Angina  Fancium.) 

Etiology. — Inflammation  of  the  tonsils  is  a  common  affec- 
tion in  young  people,  especially  between  the  ages  of  twelve 
and  thirty.  As  age  advances,  it  becomes  of  less  frequent 
occurrence,  presenting  itself  very  rarely  after  the  fiftieth 
year.  Exposure  to  cold  and  damp  is  the  most  prolific 
cause  of  tonsillitis,  especially  when  the  subject  has  already 
had  it.  Hypertrophy  of  the  tonsils  predisposes  to  it,  as  do 
also  the  rheumatic  and  scrofulous  diatheses.  It  is  an  occa- 
sional complication  of  scarlatina,  variola  and  measles.  It 
may  be  caused  traumatically  by  the  action  of  caustic  acids, 
an  impacted  foreign  body,  external  injury,  etc. 

Pathology. — The  inflammation  may  be  deep-seated  and  in- 
volve the  parenchyma  of  the  organ  (parenchymatous  tonsil- 
litis) or  be  merely  superficial  (erythematous  tonsillitis).  In 
the  former  case  the  affection  is  likely  to  manifest  itself 
principally  in  one  tonsil,  while  in  the  latter,  the  inflam- 
matory process  generally  involves  both  equally.  When  the 
inflammation  is  deep-seated,  an  abscess  generally  occurs, 
which  increases  in  size  until  opener! .  Repeated  frequently, 
parenchymatous  inflammation  of  the  tonsils  soon  induces 
hypertrophy.  The  brunt  of  the  inflammatory  process  is 
sometimes  located  in  the  crypts  of  the  tonsils  (folliculous 
tonsillitis),  a  soft,  cheesy  exudation  being  poured  out  from 
the  follicles  and  forming  a  number,  ten  to  fifteen,  of  small 
patches,  representing  the  number  of  crypts  affected. 

(281) 


'282  DISEASES   OF   THE   TONSILS. 

Symptoms. — A  chill,  more  or  less  marked,  is  generally  the 
first  symptom  experienced.  Pains  in  the  legs  and  back, 
headache  and  fever,  characterize  an  attack  of  more  than 
ordinary  intensity.  A  sense  of  dryness  and  stiffness  in  the 
throat,  with  diminution  of  secretion,  is  soon  noticed,  and 
dysphagia  soon  sets  in.  The  sufferings  of  the  patient  now 
become  quite  severe;  the  dryness  of  his  throat  tends  to  in- 
duce frequent  deglutition  in  order  to  cause  lubrication  of 
the  parts  and  this  is  accompanied  by  so  much  pain  that  the 
features  are  distorted  at  each  effort.  Inflammatory  infil- 
tration of  the  muscles  of  the  jaws  renders  opening  of  the 
mouth  difficult  and  painful,  and  in  marked  cases  the  teeth 
can  hardly  be  separated.  The  tongue  is  coated  with  a  thick 
white  fur,  and  the  breath  is  generally  intolerably  fetid; 
speech  becomes  almost  unintelligible,  as  much  from  the 
inability  to  move  the  jaws  as  through  the  interference  pre- 
sented by  the  swollen  tonsils  to  the  passage  of  air,  and  the 
inflammatory  paresis  of  the  soft  palate.  The  hearing  is 
frequently  obtunded  on  account  of  the  extension  of  the  in- 
flammation to  the  posterior  nasal  cavity  and  the  Eustachian 
tubes,  this  being  occasionally  complicated  with  abscess  of 
the  ear.  As  the  disease  progresses,  the  local  pain  becomes 
more  and  more  severe,  being  sharp  and  lancinating,  and 
frequently  extending  to  the  ears ;  deglutition,  even  of  the 
saliva,  is  so  excruciating,  that  the  patient  prefers  to  allow 
it  to  dribble  out  of  his  mouth.  In  parenchymatous  tonsil- 
litis with  tendency  to  abscess,  the  suffering  is  very  great, 
and  the  relief  is  proportionately  marked  when  the  latter 
opens  of  its  own  accord,  or  with  the  assistance  of  the  sur- 
geon's knife.  The  cervical  glands  are  enlarged  and  hard- 
ened, and  the  entire  anterior  portion  of  the  neck  occa- 
sionally appears  puffed  up  and  swollen. 

The  impossibility  of    opening   the   patient's    mouth   soon 


TONSILLITIS.  283 

after  the  early  symptoms  of  the  affection  renders  examina- 
tion of  the  inflamed  tonsils  very  difficult,  and  the  diagnosis 
has  frequently  to  be  made  without  the  benefit  of  this  source 
of  information.  The  inability  to  separate  the  jaws,  the 
fetid  breath  and  the  coated  tongue,  and  the  comparatively 
slight  systemic  disturbance,  are  pretty  sure  evidence  of  the 
trouble,  with  which  other  affections  could  hardly  be  con- 
founded. When  the  diagnosis  is  uncertain,  much  informa- 
tion can  be  gained  by  introducing  the  index  finger  into  the 
mouth  as  far  as  the  tonsils;  the  organ  will  feel  hard  and 
prominent,  while  pressure  upon  it  will  increase  pain  in- 
tensely. The  presence  of  pus  can  at  the  same  time  be 
ascertained,  as  indicated  by  Stoerk,  by  placing  the  fingers 
of  the  other  hand  behind  and  below  the  ramus  of  the  lower 
jaw,  and  compressing  the  tonsil  between  the  finger  in  the 
mouth  and  those  outside.  In  tonsillitis  with  folliculous  ex- 
udation, the  organ  is  generally  soft  to  the  touch,  while  a 
strong  light  thrown  in  between  the  partly  opened  jaws,  will 
reveal  white  spots  which  contrast  markedly  with  the  sur- 
rounding redness,  and  are  frequently  mistaken  for  diphthe- 
ritic patches.  The  differential  diagnosis  between  them, 
however,  can  be  established  without  great  difficulty  by  intro- 
ducing the  end  of  a  probe  (appropriately  curved  near  the 
extremity  for  the  purpose)  into  each  crypt.  Diphtheritic 
pseudo-membrane  is  leathery  and  resisting,  while  the  fol- 
licular  exudation  is  so  soft  that  the  end  of  the  probe  will 
easily  penetrate  through  it,  into  the  crypt,  and  generally 
detach  a  small  portion  of  cheesy  substance.  The  color  of 
the  latter  differs  also,  being  much  whiter  than  in  diphtheria, 
the  membrane  of  which  has  a  blackish  tint. 

Prognosis. — Death,  as  a  result  of  tonsillitis,  very  rarely 
takes  place.  Rupture  of  the  tonsillar  abscess  and  asphyxia- 
tion by  the  escaping  pus;  pya3mia,  which  may  occur  in  a 


284  DISEASES   OF   THE   TONSILS. 

debilitated  constitution;  extension  of  the  inflammation  to 
the  larynx  with  o?dema  as  a  sequel,  are,  however,  dangers 
which  should  be  borne,  in  mind. 

Treatment. — We  fortunately  possess,  for  this  affection,  a 
remedy  which  has  certainly  not  been  overestimated,  and 
which,  in  my  hands,  has  not  as  yet  failed  to  cut  an  attack 
short  if  administered  early.  In  erythematous  as  well  as 
parenchymatous  and  folliculous  tonsillitis,  guaiacum  can  be 
termed  a  specific.  The  method  which  I  usually  follow  in 
administering  it,  is  to  prescribe  the  ammoniated  tincture,  one 
teaspoonful  in  a  half  glassful  of  milk,  and  to  order  the  patient 
to  first  gargle  with  a  mouthful  of  the  solution,  then  to  swal- 
low it.  Enough  of  the  powder  to  cover  a  penny  is  then 
placed  far  back  on  the  tongue,  the  sufferer  being  directed  to 
keep  it  there  as  long  as  possible.  When  the  fever  is  high, 
tincture  of  aconite  root,  in  drop  doses  every  hour,  is  most 
effective,  assisting  at  the  same  time  in  diminishing  the  local 
congestion.  In  erythematous  tonsillitis,  lozenges  containing 
two  grains  of  the  resin  of  guaiac  are  generally  sufficient  to 
avert  the  inflammatory  process. 

When  the  affection  has  progressed  for  some  time,  i.e., 
more  than  two  or  three  days,  guaiac  is  no  longer  useful. 
Of  late  I  have  been  using  injections  into  the  inflamed 
masses,  of  a  ten  per  cent,  solution  of  cocaine,  using  an  or- 
dinary hypodermic  syringe  with  a  long  needle.  The  pain 
is  not  only  greatly  reduced  locally,  but  also  in  all  the  adjoin- 
ing parts.  It  seems  to  curtail  the  duration  of  the  attack, 
and  to  prevent  suppuration.  The  injections  should  be  ap- 
plied at  least  twice  daily. 

Great  relief  may  be  obtained,  when  the  tonsils  are  much 
inflamed,  by  free  depletion,  a  long,  sharp  bistoury  being  used 
to  make  a  series  of  cuts.  Five  or  six  stabs  are  generally 
sufficient  to  cause  quite  a  flow  of  blood.  In  most  cases, 


TONSILLITIS  285 

however,  this  procedure  can  only  be  conducted  with  great 
difficulty,  on  account  of  the  half-closed  mouth. 

When  suppuration  cannot  be  arrested,  warm  applications 
not  only  hasten  the  formation  of  the  abscess,  but  they  also 
decrease  the  pain.  Water,  used  as  a  gargle,  as  hot  as  it  can 
be  borne,  is  very  efficient ;  warm  poultices,  -applied  externally 
over  the  tonsils,  also  produce  a  sedative  effect;  the  in- 
halation of  steam,  medicated  with  opium,  belladonna,  coniuni, 
or  benzoin,  can  also  be  employed,  but  the  suction  necessary 
in  ordinary  inhalers,  entails  some  pain.  This  can  be  avoided 
by  using  a  steam  atomizer  on  the  principle  of  that  shown 
in  Fig.  79.  As  soon  as  fluctuation  can  be  distinctly  felt  by 
internal  and  external  digital  pressure,  it  is  better  to  evacuate 
the  abscess  than  to  allow  it  to  open  itself,  lest  it  burrow  in 
the  surrounding  parts  and  cause  dangerous  complications. 
The  best  means  to  accomplish  this,  is  to  apply  the  index 
finger  of  one  hand  over  the  seat  of  fluctuation,  the  point  of 
the  bistoury  being  slipped  alongside  and  pushed  into  the 
tonsil,  beneath  the  tip  of  the  finger  resting  over  the  abscess. 
The  patient's  head  should  be  tilted  forward  so  as  to  enable 
the  pus  to  run  out  of  the  mouth  instead  of  in  the  larynx  or 
oesophagus. 

In  folliculous  tonsillitis,  the  general  indications  are  the 
same.  The  guaiac  treatment  can  also  be  used  with  advan- 
tage when  the  patient  is  seen  early.  Generally,  however, 
the  case  is  not  seen  until  two  or  three  days  after  the  onset 
of  the  affection.  The  treatment  recommended  by  Bosworth, 
of  New  York,  has  also  proven  of  the  greatest  value  in  my 
hands,  two  drachms  of  tincture  of  the  chloride  of  iron  in 
two  ounces  of  glycerine  being  given  in  drachm  doses  every 
two  hours,  without  water.  It  makes  a  nice  golden-brown 
mixture,  which  is  quite  palatable.  It  acts  as  a  local 
astringent  in  passing  over  the  inflamed  tonsils,  decreasing 


286  DISEASES   OF   THE   TONSILS. 

markedly  the   local   congestion   while   modifying   the   action 
of  the  follicles. 

Frequent  gargling  with  lime  water  is  very  effective  in 
removing  the  exudation,  and  if  used  every  half  hour  or  so, 
its  accumulation  can  be  prevented,  thus  contributing  greatly 
to  the  patient's  comfort.  Untreated,  an  attack  of  folliculous 
tonsillitis  generally  lasts  from  six  to  ten  days. 


HYPERTROPHY   OF   THE   TONSILS. 

Etiology. — Hypertrophy  of  the  tonsils  is  generally  met 
with  in  children  and  young  persons,  being  rarely  seen  after 
the  fortieth  year,  on  account  of  the  tendency  of  these  organs 
to  disappear  gradually  after  the  age  of  thirty.  A  scrofulous 
diathesis  predisposes  to  it,  while  certain  diseases,  such  as 
diphtheria,  scarlatina,  etc.,  may  also  cause  it,  sometimes 
almost  spontaneously.  Repeated  inflammatory  processes, 
such  as  successive  attacks  of  acute  pharyngitis,  in  which 
the  tonsils  are  involved,  occasionally  act  as  a  cause.  In 
some  cases,  the  hypertrophic  process  cannot  be  traced  to 
any  distinct  etiological  factor,  the  subject  being  apparently 
in  perfect  health. 

Pathology. — As  in  hypertrophy  of  the  glandular  tissue  of 
the  naso-pharynx,  the  lymphatic  element  which  forms  an 
important  part  in  the  anatomy  of  the  tonsils,  is  probably 
causative  in  the  maintenance  of  the  early  inflammatory 
process  which  forms  the  primary  step  to  the  hypertrophic 
changes.  When  these  have  progressed  for  some  time,  the 
epithelial  layer  is  greatly  thickened,  and  the  mucosa  under 
it  is  permeated  with  lymphatic  cells  and  new  tissue  elements. 
The  size  of  the  tonsils  is  principally  increased  by  the  pro- 
liferation of  new  connective  tissue,  interspersed  with  bundles 
of  fibrous  tissue,  while  their  density  or  hardness  depends 


HYPERTROPHY  OF  THE   TONSILS.  287 

upon   the   degree  of  organization  which   these  tissues  have 
reached. 

Symptoms. — The  increased  volume  of  the  tonsils  may  be 
hardly  noticeable,  or  their  increase  in  size  may  be  so  great  as 
to  cause  them  to  touch.  One  organ  alone  may  be  hypertro- 
phied,  but,  as  a  rule,  both  are  involved  in  the  process.  Mod- 
erately enlarged,  the  tonsils  generally  occasion  but  little  if 
any  trouble.  In  many  cases  their  presence  is  unknown  until 
they  have  attained  sufficient  size  to  offer  mechanical  impedi- 
ment to  the  physiological  functions  of  the  pharynx.  In  chil- 
dren their  presence  often  occasions  a  diseased  condition  of 
the  surrounding  parts,  without  in  themselves  presenting  ac- 
tive symptoms.  Their  volume  diminishing  the  lumen  of  the 
pharynx,  the  passage  for  the  respired  air  is  diminished  in  pro- 
portion, and  the  patient  keeps  his  mouth  open  and  breathes 
through  it  to  compensate  for  the  deficiency  of  the  current 
inhaled  through  the  nose.  A  catarrhal  condition  of  the 
latter  is  engendered  through  the  accumulation  of  secretions 
on  account  of  the  limited  air-blast  to  discharge  them,  while 
the  mouth  and  throat  are  kept  dry  and  exposed  to  the  action 
of  what  foreign  particles  may  be  present  in  the  atmosphere. 
The  features  rometimes  acquire  a  silly  expression,  the  voice 
is  muffled  and  devoid  of  resonance,  snoring  and  disturbed 
sleep  and  dysphagia  are  complained  of,  while  all  the  other 
subjective  and  objective  symptoms  of  a  chronic  catarrhal 
inflammation  of  the  nose  and  throat  may  be  present,  com- 
plicated in  some  cases  with  impaired  hearing,  through  in- 
volvement of  the  Eustachian  tubes.  Frequent  recurrences  of 
acute  tonsillitis  are  the  rule.  The  obstruction  to  free  respira- 
tion rendering  an  imperfect  action  of  the  thorax  obligatory, 
its  development  is  not  properly  accomplished,  and  deformity 
of  the  chest  results  in  many  cases,  that  form  called  "  pigeon- 
breast"  being  the  most  common.  Imperfect  oxygenation  is 


288  DISEASES   OF   THE   TONSILS. 

a  natural  consequence,  and  the  child  attains  his  maturity, 
in  a  weak  state  of  health,  to  be  easily  influenced  by  all 
causes  of  disease.  Infants  are  in  some  cases  unable  to  take 
the  breast,  sucking  being  rendered  very  difficult. 

In  some  cases  the  lacunae  are  almost  continuously  filled 
with  masses  of  cheesy  secretion,  which  decomposes  in  situ 
and  evolves  a  very  fetid  odor,  contaminating  the  breath  and 
the  inspired  air. 

When  the  tonsils  become  enlarged  in  grown  subjects, 
the  deleterious  effects  are  riot  so  marked,  the  pharyngeal 
cavity  being  much  more  spacious  and  only  influenced  me- 
chanically when  they  have  attained  a  very  large  size.  Then 
the  subjective  symptoms  described  may  take  place,  the 
most  frequent  complication  being  posterior  nasal  pharyn- 
gitis and  folliculous  pharyngitis.  Acute  tonsillitis,  especially 
the  folliculous  variety,  is  also  common  in  these  cases. 

Prognosis. — As  already  stated,  enlarged  tonsils  generally 
return  to  their  normal  size  after  the  thirtieth  year.  In  them- 
selves, they  therefore  offer  no  likelihood  of  proving  dangerous 
to  life,  and  it  is  only  through  the  complications  which  they 
induce  that  their  presence  can  present  an  unfavorable  prog- 
nosis. 

Treatment. — Active  treatment  for  the  reduction  of  hyper- 
trophied  tonsils  is  always  indicated  when  they  are  sufficiently 
large  to  occasion  complications  or  to  interfere  with  proper 
respiration  through  the  nose.  In  adults,  however,  the  likeli- 
hood of  their  spontaneous  disappearance  should  be  remem- 
bered and  the  treatment  should  be  more  medicinal  than 
surgical,  unless  frequent  attacks  of  tonsillitis  renders  sur- 
gical procedures  peremptory. 

Repeated  attempts  to  reduce  hypertrophied  tonsils  by 
means  of  astringents,  have,  in  my  hands,  failed  to  produce 
anything  but  a  very  slight  diminution  in  their  bulk.  Nitrate 


HYPEKTttOPHY   OF  THE   TONSILS.  289 

of  silver  solution  instead  of  causing  a  decrease  in  their  size, 
seemed  to  cause  an  increase,  a  fact  theoretically  explained 
by  the  stimulation  induced  by  this  agent  and  its  tendency 
to  encourage  the  formation  of  new  elements.  The  solid  stick, 
however,  a  portion  of  which  is  dissolved  on  the  end  of  a 
heated  wire,  which  is  then  introduced  into  the  lacunae,  may 
be  used  with  good  effect.  Powdered  alum  and  tannin,  equal 
parts,  applied  with  the  insufflator,  seemed  to  be  productive 
of  what  benefit  was  obtained  by  means  of  astringents. 
Iodine  and  ergotine  did  not  seem  to  affect  the  glands  at 
all. 

When,  for  some  reason  or  other,  the  tonsil  cannot  be  am- 
putated, the  best  method,  in  my  opinion,  is  that  of  Donaldson, 
of  Baltimore,  who  makes  small  incisions  into  it  and  inserts 


Fig.  70. 


Tonsil  bistoury. 

a  crystal  of  chromic  acid  into  each  cut.  Galvano-cautery  is 
also  effective  when  the  tonsils  are  soft,  a  few  deep  cauteriza- 
tions in  each  tonsil  being  repeated  about  twice  a  week. 
Morell  Mackenzie  recommends  London  paste,  applied  once 
or  twice  a  week,  according  to  circumstances,  over  different 
parts  of  the  organ.  The  treatment,  although  effective,  is  very 
painful  and  tedious. 

Amputation  of  the  tonsils  can  be  performed  by  means  of 
the  bistoury,  the  tonsillotome,  the  wire  snare,  and  the  gal- 
vano-caustic  snare.  The  operation  with  the  bistoury  can  be 
employed  very  satisfactorily  in  adults,  but  not  in  children, 
on  account  of  the  resistance  which  the  latter  usually  offer, 
and  the  danger  of  cutting  the  surrounding  parts.  An  ordi- 

19 


290  DISEASES   OF   THE   TONSILS. 

nary  probe  pointed  bistoury,  with  a  long  shaft,  may  be  used 
for  the  purpose. 

The  tongue  being  depressed  by  an  assistant,  a  volcella  for- 
ceps is  fastened  on  the  tonsil  and  held  with  the  one  hand ; 
with  the  other,  the  bistoury  is  introduced  under  the  tonsil 
and  a  couple  of  sweeps  from  below  upwards  are  made  until 
it  is  cut  half-way  through.  The  instrument  is  then  with- 
drawn and  placed  over  the  organ,  and  an  incision  is  made 
from  above  until  the  first  cut  is  reached.  As  generally  per- 
formed, i.  e.,  cutting  down  from  above  until  the  tonsil  is 
detached,  there  is  always  danger  of  cutting  the  parts  below 
the  level  of  the  tongue,  especially  when,  as  frequently  hap- 
pens, the  tonsil  extends  far  down. 

The  operation  by  the  tonsillotome  presents   none  of   the 

Fig.  71. 


Mathieu's  tonsillotome. 


dangerous  features  of  that  of  the  bistoury,  and  can  be  per- 
formed without  assistant.  Mathieu's  tonsillotome,  shown  in 
Fig.  71,  is  a  very  convenient  and  satisfactory  instrument. 
Its  oval  fenestrum  encircles  a  large  tonsil  accurately  and  its 
fork  raises  the  organ  from  its  bed.  Approximation  of  the 
thumb  and  finger-rings  then  causes  penetration  of  the  cutting 
blade  through  it,  and  the  piece  comes  off  adhering  to  the 
fork. 

For  my  own  use,  I  had  constructed  the  instrument  repre- 
sented in  Fig.  72,  which  is  so  disposed  as  to  be  applicable 
to  any  degree  of  hypertrophy.  It  is  somewhat  smaller  than 
Mathieu's,  and  the  general  conformation  of  the  blades  is 
preserved;  but,  instead  of  being  furnished  with  a  side-shaft 


HYPERTROPHY   OF   THE   TONSILS.  291 

for  the  fork,  the  spear  which  takes  the  place  of  the  latter 
is  attached  to  the  main  shaft  by  means  of  a  thumb-screw. 
The  lower  edge  of  the  spear  is  straight  throughout  one-half 
of  its  length,  then  oblique,  and  rests  in  a  grooved  guide- 
screw  which  passes  through  a  slot  in  the  shaft  and  is  fast- 
ened to  the  blade.  When  in  action,  it  perforates  the  tonsil 
and  draws  it  out  without  causing  the  jar  occasioned  by  the 
gliding-screw  of  Mathieu's.  A  spear  is  made  to  replace  the 
fork,  to  avoid  the  difficulty  generally  experienced  in  sepa- 
rating the  cut-piece  from  the  latter;  it  holds  it  sufficiently 
to  prevent  its  dropping  into  the  throat,  and  can  be  easily 
withdrawn  when  partly  in  the  tonsil,  should  a  calcareous 
concretion  be  met  with. 

The  thumb-ring  is  screwed  on  the  main  shaft,  bringing 
it  in  a  direct  line  with  the  finger-rings.  By  this  arrange- 
ment the  equilibrium  of  the  instrument  is  maintained 
during  the  operation,  whether  operating  on  the  right  or 
the  left  tonsil. 

The  main  shaft  is  not  continuous  with  the  blade-rings,  as 
in  Mathieu's ;  they  are  separate,  and  the  latter  are  furnished 
with  rods  which  fit  and  move  easily  in  longitudinal  grooves 
extending  an  inch  and  a  half  along  the  side  of  the  shaft. 
By  this  arrangement  any  size  of  blade  or  ring  can  be  ad- 
justed to  the  shaft,  in  each  case  the  rings  fitting  tightly 
around  the  tonsil,  a  desideratum  for  a  neat  operation  and 
an  even  surface. 

As  represented  in  Fig.  72,  the  instrument  is  ready  for 
the  operation.  "\Ylien  the  thumb-ring  and  finger-rings  are 
approximated,  the  spear  enters  the  tonsil  and  the  beveled 
end  of  the  main  shaft  slips  under  a  small  spring  situated 
near  the  grooved  guide-screw,  from  which  a  pin,  reaching 
down  to  the  blade,  protrudes.  The  spring  being  raised,  the 
pin  is  lifted  out  of  the  hole  in  the  blade,  setting  it  free,  and 


292 


DISEASES   OF   THE   TONSILS. 


the  knife,  following  the  motion  of  the  fingers,  cuts  through 
the  tonsil. 

One  of  the  annoying  features  of  tonsillotomes  in  general 
is  the  difficulty  attending  their  cleansing.  In  this  instrument, 
traction  on  the  blade-rings  with  the  left  hand  will  cause 
them  to  slip  half-way  out  of  the  shaft,  until  a  pin,  pro- 


Author's  tonsillotorae. 
Fig.  73 


Smaller  sizes  of  blades. 
Fig.  74. 


Blade  and  rings  separated. 

jecting  from  the  lower  surface  of  one  of  them,  becomes  en- 
gaged in  a  "safety"  groove  near  the  end  of  the  knife.  The 
finger-rings  are  now  pushed  away  from  the  thumb-ring, 
causing  the  blade  to  occupy  the  position  it  held  before 
the  operation.  The  rings  being  thus  allowed  to  slip  farther 
out,  they  become  disengaged  from  the  shaft,  leaving  the 


HYPERTROPHY   OF   THE   TONSILS.  293 

blade  exposed.  The  tip  of  the  spear  is  now  turned  aside 
by  lifting  it  out  of  the  grooved  guide-screw  and  the  piece 
of  tonsil  taken  off.  Each  exposed  part  can  be  cleansed 
thoroughly  and  readjusted  in  a  few  seconds.  If  necessary, 
the  whole  instrument  can  be  taken  apart  by  merely  un- 
screwing the  thumb-ring. 

The  operation  with  the  tonsillotome  is  very  simple.  The 
tongue  being  depressed  with  the  left  hand,  the  instrument 
is  introduced  flat-wise  into  the  mouth  until  the  two  rings 
are  on  a  level  with  the  tonsil.  A  slight  turn  of  the  in- 
strument on  its  axis  will  then  bring  the  ring  over  the 
tonsil,  against  which  it  should  be  pressed  gently.  The 
fingers  and  thumb-rings  being  then  approximated,  the  tonsil 
is  perforated  by  the  lance  and  cut  off.  The  pain  pro- 
duced is  generally  slight  and  lasts  but  a  short  time. 
Bleeding  usually  follows,  but  it  almost  always  stops  after  a 
few  seconds,  especially  if  a  gargle  of  ice-water  is  used.  Oc- 
casionally it  lasts  longer,  stopping  spontaneously  in  ten  or 
fifteen  minutes.  Profuse  hemorrhage  occurs  in  perhaps  one 
out  of  every  five  hundred  operations,  while  an  alarming  flow 
does  not  occur  in  one  out  of  a  thousand.  It  has  been  my 
misfortune  to  meet  with  two  such  cases ;  in  one,  a  medical 
student,  seven  consecutive  hemorrhages  at  from  three  to 
fifteen  hours'  intervals,  occurred,  pressure  alone,  of  all  the 
means  employed,  acting  satisfactorily.  In  the  second  case, 
a  boy  of  seventeen,  the  bleeding  occurred  two  hours  after 
the  operation,  and  torsion  of  the  tonsillar  artery  was  re- 
sorted to  with  success.  Before  I  had  these  two  cases,  I  was 
inclined  to  consider  the  danger  of  hemorrhage  as  overrated ; 
since  then,  I  have  come  to  the  conclusion  that  I  was  wrong, 
and  that  the  likelihood  of  its  occurrence  should  be  borne 
in  mind,  especially  since  a  number  of  cases  are  on  record 
in  which  a  fatal  result  could  not  be  prevented.  Hemorrhage 


294-  DISEASES  OF  THE  TONSILS. 

is  more  to  be  feared  in  adults  than  in  children ;  the  vessels 
being  larger,  the  clots  cannot  as  rapidly  cause  occlusion, 
while  the  less  elastic  arterial  walls  are  collapsed  with  greater 
difficulty.  In  my  two  cases  of  profuse  hemorrhage,  the 
tonsils  were  exceedingly  hard  to  penetrate,  a  fact  which  led 
me  to  believe  that  the  cut  arteries  were  maintained  open 
by  the  surrounding  fibrous  elements  adhering  to  them.  I 
am  therefore  inclined  to  consider  hemorrhage  more  likely 
in  hard  than  in  soft  tonsils. 

Prior  to  operating,  I  now  introduce  into  the  parenchyma 
of  the  tonsil,  with  an  hypodermic  syringe,  as  much  as  I 
can  of  a  ten  per  cent,  solution  of  cocaine ;  its  constricting 
action  upon  the  blood-vessels  renders  the  organ  compara- 
tively exsanguine,  preventing  almost  entirely  the  usual 
slight  bleeding,  and  limiting  the  likelihood  of  subsequent 
hemorrhage.  The  slight  pain  incident  upon  the  operation 
is  also  prevented. 

Dr.  Mackenzie's  tanno-gallic  acid  gargle  is  an  excellent 
mixture  for  the  prevention  of  secondary  hemorrhage.  It  is 
composed  of  six  drachms  of  tannic  acid  and  two  drachms  of 
gallic  acid  in  an  ounce  of  water;  half  a  teaspoonful  of  this 
mustard-like  liquid  being  slowly  sipped  at  short  intervals,  it 
penetrates  into  the  cut  surface,  assisted  by  the  act  of  deglu- 
tition. Amputation  by  the  snare  is  a  rather  slow  process 
as  compared  with  that  by  the  tonsillotome,  but  what  danger 
of  hemorrhage  may  exist  is  much  diminished.  The  loop 
being  passed  over  the  tonsil,  the  wire  is  gradually  drawn 
home,  fifteen  to  twenty  minutes  being  employed.  In  some 
cases  the  growth  is  sessile,  and  cannot  be  grasped;  a  long 
needle  may  be  used  to  transfix  it,  as  in  large  anterior  nasal 
hypertrophies  (see  Fig.  36).  The  galvano-caustic  snare  is 
manipulated  in  the  same  manner  but  the  operation  can  be 
performed  more  rapidly.  Cocaine  is  of  great  assistance  in 


IlELAXATION   OF   THE   SOFT   PALATE   AND    UVULA.  295 

these  operations  and  should  invariably  be  employed  as 
indicated  above. 

•  In  some  cases,  the  enlarged  tonsil  is  found  adhering  to  the 
sides  of  the  pillars  with  which  it  is  in  contact.  It  should  be 
detached  before  the  operation,  by  slipping  the  end  of  a  probe 
between  pillar  and  tonsil  until  these  are  separated. 

The  after-treatment  of  these  operations  is  of  the  greatest 
simplicity.  The  cut  surface  heals  in  a  few  days,  without 
causing,  in  most  cases,  the  least  systemic  disturbance. 
Highly  seasoned  articles  of  food  should  be  avoided,  as  well 
as  hot  liquids. 

Systemic  treatment  is  important  in  many  cases.  Scrofula 
should  be  met  with  appropriate  remedies,  such  as  the  iodides, 
hypophosphites,  and  general  tonics.  Anemia,  which  is  a 
frequent  result  of  hypertrophic  tonsils  of  long  standing, 
through  imperfect  oxygenation  of  the  blood,  is  best  treated 
with  Rabuteau's  pills  of  iron,  permanganate  of  potash  or 
arsenic.  In  short,  all  existing  abnormal  conditions  should 
receive  proper  attention. 

KELAXATION   OF   THE   SOFT   PALATE   AND   UVULA. 

(Synonyms  : — Elongated  Uvula  ;    Relaxed  Throat ;    Relaxed 
Throat  and  Uvula.) 

Etiology. — Relaxation  of  the  soft  palate  and  uvula  is  gen- 
erally due  to  chronic  catarrhal  inflammation  of  the  posterior 
nasal  cavity  and  of  the  pharynx.  In  the  former,  the  relaxa- 
tion is  not  only  due  to  extension,  by  continuity  of  tissue,  of 
the  inflammatory  process,  but  it  is  mainly  caused,  in  my 
opinion,  by  the  constant  hacking  and  scraping  to  which  these 
cases  become  accustomed  in  their  efforts  to  clear  the  vault 
of  offending  discharges.  A  relaxed  and  weakened  condition 
of  the  system,  through  loss  of  tone  of  the  muscular  power, 


296  DISEASES   OF   THE   TONSILS. 

is  also  a  frequent  cause,  the  azygos  uvulae  and  palatal  muscles 
taking  part  in  the  general  debility,  and  allowing  the  palate 
and  uvula  to  drop  perpendicularly  on  the  base  of  the  tongue, 
where  they  are  kept  congested  by  the  efforts  of  the  patient 
to  dislodge  a  supposed  foreign  object.  Gastric  affections, 
immoderate  smoking  and  drinking,  are  also  frequent  causes, 
while  cerebral  affections  and  diphtheria,  by  causing  paralysis 
of  the  soft  palate,  may  cause  it  to  appear  relaxed. 

Pathology. — In  elongation  due  to  catarrhal  inflammation, 
there  is  at  first  mere  congestion,  the  blood-vessels  being 
engorged  and  the  cellular  tissue  somewhat  oedematous. 
Gradually,  there  is  inflammatory  infiltration,  which  finally 
becomes  organized,  and  the  enlargement,  which  at  first  was 
fugitive,  is  made  permanent.  The  relaxation  may  implicate 
the  soft  palate  and  the  uvula,  or  the  latter  only. 

Symptoms. — A  tickling,  irritating  sensation,  which  induces 
frequent  fits  of  coughing,  is  experienced  in  the  majority 
of  cases.  A  feeling  as  if  a  foreign  body  were  in  the  throat 
causes  the  patient  to  make  violent  efforts,  by  hacking,  to 
clear  his  throat.  Nausea  is  a  frequent  symptom,  most 
marked  on  rising,  the  upright  position  causing  the  uvula 
to  rest  against  the  base  of  the  tongue.  Upon  lying  down, 
it  falls  back  upon  the  posterior  wall  of  the  pharynx,  and 
maintains  a  constant  irritation,  which  soon  establishes  a 
chronic  inflammatory  process.  Snoring  is  usually  marked, 
and  the  sleep  is  disturbed  by  the  obstruction  presented 
to  normal  respiration  by  the  relaxed  palate,  which  acts  like 
a  valve,  allowing  the  air  to  pass  downward,  but  interfering 
with  its  expulsion.  When  the  uvula  is  very  long,  it  may 
cause  spasm  of  the  glottis,  and,  according  to  Bosworth, 
genuine  spasmodic  asthma.  The  tongue  is  usually  coated 
at  the  base  by  a  yellowish-green  fur,  which  resembles  that 
caused  by  hepatic  engorgement.  In  some  cases,  the  hacking 


RELAXATION    OF   THE   SOFT   PALATE   AND    UVULA. 


297 


cough,  the  irritable  throat,  and  the  increased  salivary  secre- 
tions affect  the  patient's  health  greatly,  and  he  may  appear 
as  if  suffering  from  a  much  more  formidable  affection. 

Treatment. — When  the  relaxation  involves  the  soft  palate 
only,  astringents  are  sometimes  quite  effective,  but  they 
must  be  used  in  strong  solution.  Alum  is  about  the  most 
effective  agent  we  possess ;  in  the  proportion  of  gr.  xx-Ij ;  it 
may  be  used  as  a  gargle  every  two  or  three  hours,  generally 
with  the  happiest  results.  Ferric  alum,  sulphate  of  zinc, 
and  tannin,  may  also  be  used  with  good  effect  in  solutions 
of  gr.  xv-! j.  When  this  does  not  succeed,  or  when  the 

Fig.  75- 


Author's  uvulatome. 


relaxation  is  limited  to  the  uvula,  ablation  of  the  latter  is 
the  only  satisfactory  measure.  This  may  be  accomplished 
with  a  pair  of  long,  curved  scissors,  the  uvula  being  steadied 
with  a  paii'  of  suitable  forceps.  This  procedure,  although 
apparently  easy,  is  sometimes  quite  difficult,  owing  to  the 
constant  up  and  down  motion  of  the  uvula.  Again,  the 
scissors,  in  closing,  allow  the  organ  to  slip  out  of  its  grasp, 
after  cutting  perhaps  half-way  through  it. 

A  much  more   satisfactory  instrument  is   that   shown   in 
Fig.    75.     It   consists  of  a  pair   of  strong  scissors  with  the 


298  DISEASES   OF   THE   TONSILS. 

handles  slightly  bent.  Its  lower  surface  is  armed  with  a 
pair  of  toothed  claws,  the  stems  of  which  are  united,  and 
are  connected  with  the  handles  by  means  of  twro  little  arms. 
These  being  attached  loosely,  the  claws  have  free  longitu- 
dinal motion,  being  guided  by  the  pivot-screw  of  the  scissors, 
and  kept  in  position  by  a  cap  which  not  only  serves  that 
purpose,  but  also  approximates  the  toothed  edges  of  the 
claws  by  the  resistance  it  offers  to  their  outer  edge,  as  they 
are  drawn  backward  by  the  approximation  of  the  handles. 

The  instrument  being  held  with  the  palm  of  the  hand 
directed  toward  the  operator,  that  is  to  say,  with  the  thumb 
and  finger  passed  through  the  rings  from  below  upward 
(the  bend  being  just  sufficient  to  prevent  them  from  inter- 
fering with  the  line  of  vision)  it  is  introduced  closed  into 
the  mouth.  As  soon  as  the  point  has  reached  the  uvula,  the 
rings  are  separated,  and  the  organ  hangs  between  the  teeth 
of  the  claws.  The  rings  being  now  approximated,  the  claws 
close  on  the  uvula  before  the  blades  touch  it,  hold  it  fast, 
and  bring  it  forward  by  bending  it  at  its  base.  The  scissors 
cutting  it  in  that  position,  the  cut  surface  is  oblique  and 
posterior.  When  food  is  swallowed,  the  horizontal  surface 
obtained  with  other  instruments  is  exposed  to  the  bolus,  and 
scraped  and  kept  sore  by  it  for  several  days.  With  the 
posterior  oblique  surface  obtained  with  this  instrument,  the 
bolus  only  touches  the  anterior  surface  of  the  stump,  the 
cut  surface  resting  against  the  pharynx.  The  healing  pro- 
cess is  more  rapid,  and  a  better  stump  is  obtained;  slipping 
of  the  uvula  between  the  blades  is  impossible,  and  the  cut 
is  always  complete. 

A  ten  per  cent,  solution  of  cocaine,  applied  just  before 
the  operation,  renders  it  almost  painless,  and  prevents  the 
slight  bleeding  which  usually  occurs.  The  after-effects  of 
the  operation  are  slight  local  pain,  increased  by  the  act  of 


RELAXATION  OF  THE  SOFT  PALATE  AND  UVULA. 

deglutition.  Well-seasoned  food,  hot  liquids,  and  smoking, 
should  be  avoided.  An  occasional  application  of  a  four  per 
cent,  solution  of  cocaine  during  the  day  limits  markedly  the 
unpleasant  after-effects  and  promotes  resolution  of  the  cut 
surface. 


CHAPTER  XXI. 

THE   LAKYNX. 
ANATOMY. 

THE  larynx  may  he  considered  as  an  expansion  of  the 
upper  portion  of  the  trachea  or  windpipe,  which  lies 
between  the  pharynx,  of  which  it  forms  the  anterior  wall, 
and  the  lower  portion  of  the  base  of  the  tongue.  Its 
superior  aperture  slants  toward  the  pharynx,  and  is  covered 
by  a  leaf-like  lid,  the  epiglottis,  which  is  attached  to  its 
anterior  margin  and  closes  from  before  backward.  The 
larynx  is  connected  with  the  surrounding  parts  by  muscles 
and  ligaments,  the  former  of  which  serve  to  elevate  it  during 
deglutition  and  phonation.  It  forms  in  the  neck,  the  promi- 
nence generally  called  "  Adam's  apple." 

Although  the  larynx  is  in  shape  an  expansion  of  the 
trachea,  its  framework  is  not  like  that  of  the  latter,  com- 
posed of  cartilaginous  rings,  but  its  walls  are  formed  by 
two  broad  plates  of  cartilage,  which  meet  anteriorly  and 
are  widely  separated  posteriorly,  thus  forming  a  triangular 
space  between  them,  with  its  base  facing  the  pharynx. 
United  in  this  manner,  they  form  the  thyroid  cartilage,  called 
so  011  account  of  its  resemblance  to  a  shield. 

The  anterior  angle  of  the  thyroid  cartilage  is  hardly  more 
than  an  inch  from  above  downward,  a  deep  depression  in 
its  superior  margin  diminishing  its  perpendicular  diameter 
greatly.  Posteriorly,  however,  this  diameter  is  much  greater, 
each  wing  being  furnished  with  two  perpendicular  horns 
or  cornua,  one  above  and  the  other  below,  the  former  being 
somewhat  longer  and  thinner  than  the  latter,  which  is  short 
(300) 


ANATOMY.  301 

and  thick.  The  upper  horns  are  connected  with  the  hyoid 
bone  above  by  means  of  ligaments.  The  two  lower  horns 
might  be  called  the  pillars  of  the  thyroid  cartilage,  as  they 
form  its  posterior  support,  resting  upon  the  two  facets  of 
the  cricoid  cartilage,  immediately  below. 

The  cricoid  cartilage,  called  so  on  account  of  its  resem- 
blance to  a  seal  ring,  separates  the  thyroid  cartilage  from 
the  trachea,  its  seal  or  broad  portion  being  turned  towards 
the  pharynx.  On  each  side  of  the  seal  is  a  small  promi- 
nence, which  in  turn  is  furnished  with  a  small  hollow  facet. 
In  the  two  facets  thus  formed,  rest  the  inferior  cornua  of 
the  thyroid  cartilage,  which  are  held  in  place  by  means  of  a 
capsular  ligament,  so  disposed  as  to  allow  approximation  of 
the  two  cartilages  anteriorly. 

While  the  sides  of  the  seal-like  portion  of  the  cricoid  car- 
tilage support  the  inferior  cornua,  its  upper  border  becomes 
the  resting  point  of  two  other  cartilages,  the  arytenoid 
cartilages,  which  stand  some  distance  from  the  median  line. 
Each  cartilage  is  pyramidal  in  form,  its  antero-posterior 
diameter  being  much  longer  at  the  base  than  its  lateral,  and 
resembles  greatly  in  shape  the  pointed  paper  hats  made  by 
children.  Like  the  cornua  of  the  thyroid,  the  arytenoid 
cartilages  rest  upon  facets,  to  which  they  are  secured  by 
ligaments,  in  such  a  manner  as  to  be  freely  movable;  rest- 
ing upon  these  facets,  as  they  do,  only  by  a  small  portion 
of  their  inferior  surface,  near  the  middle,  they  can  be  piv- 
oted upon  their  support  like  the  needle  of  a  marine  compass, 
and  even  be  slipped  up  towards  the  median  line. 

In  the  rotatory  faculty  of  the  arytenoid  cartilages,  we  have 
the  mechanical  basis  for  the  adduction  and  abduction  of 
the  vocal  bands,  wrongly  called  the  vocal  cords  (not  being 
rounded  cords  as  the  name  would  imply),  which  are  two  thin 
but  strong  bands  of  yellow  elastic  tissue,  covered  on  their 


302  THE   LAKYNX. 

surface  by  a  thin  layer  of  mucous  membrane,  and  attached 
anteriorly  to  the  retiring  angle  of  the  thyroid  cartilage  near 
its  lower  border,  and  posteriorly  to  the  anterior  angle  of  the 
base  of  the  arytenoid-  cartilage.  The  manner  in  which  ap- 
proximation and  separation  of  the  vocal  bands  is  accom- 
plished is  as  follows  :— 

Alii  net  ion. — The  posterior  aspect  of  the  seal  of  the  cricoid 
cartilage  presents  two  shallow  depressions,  one  on  each  side 
of  the  middle  line,  which  serve  for  the  attachment  of  the 
posterior  crico-arytcnoid  muscles,  whose  fibres '  are  directed 
upward  and  outward  and  are  inserted  at  the  posterior  angle 
of  the  arytenoid  cartilage.  When  these  muscles  contract, 
they  approximate  these -posterior  angles,  and  the  anterior 
angles  of  the  arytenoid  cartilages  are  rotated  around,  sepa- 
rating their  extremities.  The  vocal  bands  being  attached 
to  the  latter,  are  also  widely  separated,  the  triangular  open 
space  between  them  being  called  the  glottis. 

Adduction. — To  approximate  the  vocal  bands,  we  have 
another  set  of  muscles,  the  lateral  crico-arytenoidei,  whose 
broad  attachments  are  on  the  upper  border  of  the  narrow 
or  ring  portion  of  the  cricoid,  while  their  fibres,  which  are 
directed  upward  and  backward  and  somewhat  inward,  are 
also  inserted  at  the  posterior  angle  of  the  arytenoid.  Con- 
traction of  these  muscles  causes  the  antagonizing  action  to 
that  of  the  posterior  crico-arytenoidei,  and  by  pulling  the 
posterior  extremities  of  the  arytenoid  cartilage  outward,  they 
cause  approximation  of  the  bands.  In  death,  or  when  both 
sets  of  muscles  are  paralyzed,  the  muscles  are  neither  com- 
pletely approximated  or  separated ;  they  remain  half  way, 
in  the  so-called  "cadaveric"  position. 

The  lateral  cricoid-arytenoid  muscles  are  not  sufficient, 
however,  to  cause  approximation  of  the  whole  length  of  the 
bands.  A  delicate  piece  of  soft  cartilage  which  is  imbedded 


ANATOMY. 

in  each  vocal  band  and  attached  also  to  the  anterior  angle 
of  the  arytenoid  cartilage,  called  the  vocal  process,  limits  the 
action  of  the  bands,  and  when  the  lateral  crico-arytenoidei 
alone  act,  their  points  come  together  with  the  portion  of 
the  cords  anterior  to  them,  leaving  a  triangular  opening 
behind.  In  order  to  close  this,  when  necessary,  there  is 
another  muscle,  the  arytenoideus,  composed  of  three  sets  of 
fibres,  two  oblique  and  one  horizontal,  which  is  attached  to 
the  internal  surface  of  each  arytenoid  cartilage,  and  which, 
by  contracting,  approximates  the  cartilages  by  causing  them 
to  slide  upward,  upon  their  facets,  thereby  approximating 
that  part  of  the  vocal  bands  containing  the  vocal  processes 
and  consequently  the  entire  length  of  the  bands. 

The  vocal  bands  are  thus  opened  by  the  posterior  crico- 
arytenoidei,  partially  closed  by  the  lateral  crico-arytenoidei^ 
and  completely  closed  by  the  arytenoideus ;  thus  making  three 
sets  of  muscles  concerned  in  opening  and  closing  the  glottis. 

Extension. — Extension  of  the  vocal  cords  is  produced  by 
the  tilting  upward  of  the  cricoid  cartilage  upon  the  thyroid, 
the  articulation  of  the  inferior  cornu.a  of  the  thyroid  car- 
tilage and  the  cricoid  serving  as  fulcrum.  The  part  of  the 
seal  upon  which  the  arytenoid  cartilages  are  attached  being 
much  higher,  comparatively,  than  the  location  of  the  fulcrum, 
when  the  anterior  portion  of  the  cricoid  cartilage  is  raised, 
the  upper  border  of  the  seal  is  forced  back,  drawing  the 
arytenoid  cartilages  with  it,  and  stretching  the  vocal  bands 
which  are  attached  to  them.  The  muscles  which  accom- 
plish this  purpose  are  the  tliyro-cricoidei,  composed  of  two 
fasciculi  on  each  side,  which  are  attached  to  the  external 
surface  of  the  thyroid  cartilage  near  its  lower  edge,  and, 
being  directed  forward  and  downward,  are  inserted  upon 
the  external  surface  of  the  cricoid.  When  these  muscles 
contract  they  draw  the  cricoid  cartilage  upward  under  the 


304  THE   LAEYNX. 

thyroid,  stretching  slightly,  at  the  same  time,  the  anterior 
portion  of  the  trachea. 

Relaxation. — Relaxation  of  the  vocal  bands  after  the  thyro- 
cricoid  muscles  have  extended  them,  is  accomplished  by  the 
tliyro-arytenoidei  or  vocal  muscles,  each  composed  of  three 
fasciculi,  mainly  by  approximating  the  arytenoid  cartilages 
and  the  thyroid  cartilage.  The  first  or  straight  fasciculus  is 
composed  of  flat  horizontal  fibres  which  are  closely  connected 
with  the  vocal  band,  and  are  inserted  into  the  inferior  bor- 
der of  the  arytenoid  cartilage.  The  second  is  triangular  in 
shape,  the  base  of  the  triangle  being  attached  to  the  ante- 
rior surface  of  the  arytenoid  cartilage,  while  the  third  fasci- 
culus is  also  triangular  in  shape,  the  apex  being  attached  to 
the  infeiior  border  of  the  arytenoid,  while  its  base  is  inserted 
at  the  point  of  common  origin  in  the  retiring  angle  of  the 
thyroid  cartilage,  sending  diverging  fibres  to  the  sides  of 
the  cavity  from  origin  to  insertion. 

The  vocal  bands  are  thus  extended  by  the  contraction  of 
the  thyro-cricoid  muscles,  and  relaxed  by  the  contraction  of 
the  thyro-arytenoidei,  a  perfect  equilibrium  being  maintained 
between  the  two  sets  of  muscles  so  as  to  insure  absolute 
steadiness  in  the  production  of  tones.  Another  impor- 
tant set  of  muscles  is  that  which  causes  the  descent  of 
the  lid  of  the  larynx,  the  epiglottis,  and  which  contracts, 
and  even  closes  in  some  cases,  the  upper  aperture  of  the 
larynx. 

Depression  of  the  Epiglottis. — The  epiglottis  is  maintained 
raised  some  distance  from  the  laryngeal  aperture  principally 
by  a  ligament  which  connects  its  upper  surface  with  the 
base  of  the  tongue,  the  glosso-epiglottic  ligament.  The  ordi- 
nary position  of  the  epiglottis  during  respiration  is  to  stand 
a  certain  distance  above  the  larynx,  but  when  food  or  drink 
is  swallowed,  it  is  closed  upon  the  larynx  to  prevent  the 


ANATOMY.  305 

ingression  into  it  of  the  liquids  or  solids  taken.  This  is 
accomplished  by  the  thyro-cpiglottideus,  a  small  muscle  which 
is  inserted  on  each  side  of  the  epiglottis,  and  attached  to 
the  inner  surface  of  the  thyroid  cartilage.  Its  contraction 
causes  the  epiglottis  to  adapt  itself  closely  to  the  aper- 
ture of  the  larynx,  which  it  closes  securely.  , 

Contraction  of  the  Laryngeal  Aperture. — The  muscles  which 
contract  the  aperture  of  the  larynx,  and  are  capable  of 
closing  it  completely  in  case  of  loss  of  the  epiglottis,  are 
the  superior  aryteno-epiglottidei,  which  arise  from  the  apices 
of  the  arytenoid  cartilages,  and  curving  around  in  the  fold 
of  mucous  membrane  forming  the  edge  of  the  laryngeal 
aperture,  the  ary-epiglottic  fold,  into  which  the  greater  por- 
tion of  their  fibres  are  lost,  are  finally  inserted  at  the  base  of 
the  epiglottis.  Their  contraction  causes  approximation  of  the 
upper  portion  of  the  laryngeal  cavity  and  holds  the  office 
of  the  epiglottis  when  this  is  gone.  In  order  to  further 
secure  the  integrity  of  the  larynx  during  deglutition,  a  third 
mechanism  enters  into  play.  Immediately  below  the  edge 
of  the  laryngeal  aperture  and  a  short  distance  above  the 
vocal  bands,  are  the  ventricular  bands,  sometimes  called  the 
false  vocal  cords,  which  extend  from  the  receding  angle  of 
the  thyroid  cartilage  to  the  anterior  surface  of  the  aryte- 
noid cartilages,  parallel  with  the  true  vocal  cords.  They 
are  formed  by  the  superior  thyro-arytenoid  ligament  and 
some  muscular  fibres.  Just  before  the  epiglottis  comes 
down  on  the  larynx,  the  ventricular  bands  are  approx- 
imated, the  cushion  of  the  epiglottis,  a  pad-like  thickening 
upon  its  under  surface,  filling  the  gap  between  it  and  the 
ventricular  bands  and  closing  the  slit  between  the  latter 
effectively. 

Lubrication  of  the  Vocal  Bands. — Between  the  ventricular 
band  and  the  vocal  band  on  each  side,  is  an  elliptical 

20 


306  THE   LARYNX. 

space,  the  ventricle,  which  extends  antero-posteriorly  from 
the  thyroid  to  the  aryteuoid  cartilage,  and  forms  a  sort 
of  pocket  between  the  ventricular  band  and  the  wall  of  the 
larynx.  Into  it  opens  the  laryngeal  sac,  an  upright  cavity, 
which  is  really  but  an  extension  upward  of  the  ventricle, 
about  the  size  of  a  small  bean.  The  mucous  membrane 
lining  this  sac  is  thickly  studded  with  small  racemose 
glands,  which  are  constantly  pouring  out  a  glairy  mucus 
that  keeps  the  cords  lubricated.  The  ventricle  being  situated 
between  the  internal  wall  of  the  larynx  and  the  ventricular 
band,  it  is  in  a  favorable  position  to  be  compressed,  this 
being  accomplished  by  the  contraction  of  the  inferior 
aryteno-epujloUideus  (compressor  sacculi  laryngis  of  Hilton), 
which  arises  from  the  anterior  angle  of  the  aryteiioid  car- 
tilage, and  is  inserted  into  the  margin  of  the  epiglottis, 
after  having  passed  over  the  sac,  through  the  ventricular 
band. 

The  larynx  is  united  with  the  surrounding  parts  by 
means  of  muscles  and  ligaments.  The  former,  which  are 
called  the  extrinsic  muscles  (in  contradistinction  to  those 
which  unite  the  different  parts  of  the  larynx  together — the 
intrinsic  muscles),  move  the  larynx  up  and  down  in  the 
throat  during  phonation  and  deglutition,  and  maintain  it 
steady  during  the  emission  of  sound. 

Elevation  is  accomplished  principally  by  the  thyro-hyoid 
muscles,  which  are  attached  to  the  hyoid  bone  and  to  the 
upper  portion  of  the  thyroid  cartilage.  These  are  prin- 
cipally instrumental  in  insuring  the  steadiness  of  the  larynx, 
which  they  raise  during  phonation.  In  the  production  of  low 
tones,  the  larynx  is  depressed  by  the  sterno-thyroid  muscle 
which  connects  the  sides  of  the  thyroid  cartilage  with  the 
sternum. 

The    Laryngeal    Mucous    Membrane. — The    different    parts 


ANATOMY.  307 

described,  comprising  the  framework  and  muscular  supply 
of  the  larynx,  are,  throughout  their  entire  extent,  covered 
with  mucous  membrane.  Between  the  epiglottis  and  the 
tongue,  it  forms  three  folds, — the  glosso-epiglottic  folds — one 
exactly  in  the  middle,  forming  the  glosso-epiglottic  ligament, 
before  alluded  to,  and  two  lateral,  which  form  between  them 
two  shallow  fossae  into  which  foreign  bodies  frequently 
become  impacted.  On  each  side  of  the  epiglottis  the  mucous 
membrane  forms  another  fold,  the  pliaryncjo-epiglottic  fold 
which  unites  the  epiglottis  to  the  pharynx.  This  forms 
on  each  side  the  upper  limit  of  another  cavity,  the  pyriform 
sinus,  much  deeper  than  the  glosso-epiglottic  fossae,  which 
are  also  frequently  invaded  by  foreign  bodies. 

The  upper  border  of  the  larynx  is  formed  by  a  redupli- 
cation of  the  membrane  called  the  ary-epiglottic  fold.  The 
membrane  is  here  loosely  attached  to  the  underlying  parts, 
especially  in  the  region  of  the  arytenoid  cartilages,  which 
are  thus  enabled  to  rotate  freely.  Over  the  ventricular 
bands  it  is  somewhat  more  adherent,  but  again  becomes 
loose  in  the  ventricle.  The  laxity  of  the  membrane  in  these 
situations  renders  them  more  liable  to  oadema  than  other 
parts.  It  adheres  firmly  to  the  vocal  cords,  forming  a  sharp 
edge  at  their  border,  then  continuing  obliquely  downward 
to  the  trachea. 

The  epithelium  is  principally  of  the  ciliated  variety.  The 
vocal  bands,  however,  are  covered  along  the  edge  and  a 
short  distance  beyond,  l>y  pavement  or  tesselated  epithelium, 
the  cells  being  especially  large.  The  posterior  surface  of 
the  epiglottis  and  the  inter-arytenoid  space  are  also  lined 
with  pavement  epithelium. 

Arteries. — The  larynx  is  supplied  by  branches  of  the 
superior  and  inferior  thyroid  arteries.  The  superior  laryngeal 
which  is  derived  from  the  former,  penetrates  into  it  by 


308  THE   LARYNX. 

passing  through  the  thyro-hyoid  membrane.  The  middle 
laryngeal^  also  a  branch  of  the  superior  thyroid,  passes  over 
the  thyro-cricoid  membrane  and  unites  with  its  fellow,  after 
having  sent  a  branch  into  the  laryngeal  cavity.  The  inferior 
larynycal,  a  secondary  branch  of  the  inferior  thyroid,  sends 
a  branch  to  the  posterior  crico-arytenoid  muscle,  while 
another  meets  with  a  branch  of  the  superior  laryngeal. 

Nerves. — The  nervous  supply  of  the  larynx  is  derived 
from  the  superior  and  inferior  or  recurrent  laryngeal,  both 
branches  of  the  pneumogastric.  The  former  is  a  sensory 
nerve  almost  exclusively,  supplying  motor  nerves  only  to 
the  tliyro-epiglottidean,  ary-epiglottidean,  and  crico-thyroid 
muscles.  The  recurrent  laryngeal  is  exclusively  a  motor 
nerve  and  sends  branches  to  all  the  muscles  of  the  larynx, 
with  the  exception  of  the  three  enumerated. 

PHYSIOLOGY. 

The  principal  physiological  function  of  the  larynx  is  the 
production  of  voice.  During  respiration  the  vocal  bands  are 
separated,  this  separation  being  especially  marked  during 
the  inspiratory  act,  when  the  posterior  crico-arytenoid 
muscles  approximate  as  closely  as  possible  the  posterior 
processes  of  the  arytenoid  cartilages,  thus  abducting  the 
vocal  bands  to  their  utmost  extent.  In  expiration,  however, 
these  muscles  cease  to  act,  and  the  vocal  bands  are  main- 
tained separated  by  the  current  of  expired  air  which  forces 
them  apart.  If  now  a  sound  is  to  be  emitted,  in  connection 
with  the  expired  current,  another  set  of  muscles  is  brought 
into  play,  the  lateral  crico-arytenoidei,  which  pull  the  pos- 
terior processes  of  the  arytenoid  cartilages  outward,  and 
cause  adduction  of  the  vocal  bands,  leaving  a  mere  slit 
between  them.  The  air  impinging  upon  the  edge  of  the 
bands,  causes  them  to  vibrate,  just  as  the  tongue  of  a 


PLATE  vn. 


PLATE   VII. 


ANATOMY   OF   THE   LARYNX. 


a.  Thyroid  cartilage. 

6.  Cricoid  cartilage. 

C.  Arytenoid  cartilage 

d.  Cartilage  of  Santorini 

e-  Crico-thyroid  membrane. 

f.  Vocal  band. 

a.  Arytenoideus  muscle. 

ft:  Lateral  crico-arytenoid  muscle. 

i.   Posterior          "  " 

j.  Epiglottis. 

k.  Vocal  process 


PIGUKES    I   TO  9. 


m   Cartilage  of  Wrisberg. 

n.   Aryteno-epiglottic  fold. 

O1   Upper  fasciculus  of  thyro-arytenoid  muscle. 

0-.  Middle        "  "  "  « 

o*.  Lower         "  "  " 

p.   Ventricle  of  the  larynx. 

q.    Laryngeal  sac. 

r.    Ventricular  band 

S.    Superior  aryteno-epiglottic  muscle. 

/  if  t~.  Two  fasciculi  of  thyro-cricoid  muscle. 

U.    Superior  thyro-arytenoid  ligament. 


ABDUCTION  AND  ADDUCTION. 


FIG.  i. 

POSTERIOR   VIEW. 

Vocal  bands  abducted  by  con- 
traction of  posterior  crico-aryte- 
noids  (arytenoideus  cut  off). 


FIG.  2. 

LATERAL  VIEW. 
Section  of  larynx  showing  rela- 
tion   of   adductor    and    abductor 
muscles. 


FIG.  3. 

POSTERIOR  VIEW 
Vocal  bands  adducted  partially 
by   contraction  of   lateral   crico- 
arytenoids  (arytenoideus  not  hav- 
ing acted). 


FIG.  4.  FIG.  5. 

HORIZONTAL  SECTION  OP  LARYNGEAL  FRAMEWORK,  ABOVE  VOCAL  BANDS. 
Vocal  bands  in  abduction.  Vocal  bands  in  partial  adduction. 


FIG.  6. 

LATERAL  SECTION. 
Relaxation     of      vocal      band 
through     contraction     of    thyro- 
arytenoids     and     relaxation     of 
thyro-cricoids. 


EXTENSION  AND  RELAXATION. 

FIG.  7. 

LATERAL  SECTION. 
Interior  of  larynx.     Flaps  raised 


to  show  laryngeal  sac,  and  the  rela- 
tion of  muscles  with  the  mucous 
membrane. 

FIG.  9. 

ANTERIOR  SECTION. 
Interior  of  larynx  and  relation 
of  muscles. 


FIG.  8. 

LATERAL  SECTION. 
Extension    of   vocal    band    by 


elevation  of  the  cricoid  cartilage 
through  contraction  of  the  thyro- 
cricoid  muscles  and  relaxation  of 
the  thyro-arytenoids. 


FIG.  10. 

INNERVATION  OP  THE  LARYNX. 

Posterior  section  of  neck  and  upper  part  of  chest  showing  the  course 
of  the  pneumogastric  nerves,  their  branches,  and  their  relations.  Lateral 
half  of  trachea  and  quarter  of  larynx  cut  off. 


A  Sf  A1.  Pneumogastric  nerve. 
B  If  Bl.  Superior  laryngeal. 
L\  Right  recurrent  laryngeal. 

D.  Right  lung. 

E.  Left  recurrent  laryngeal. 

F.  Branch  of  superior  larvngeal 

a.  CEsophagus. 

b.  Aorta. 

C.    Pulmonary  artery. 

d.  Trachea. 

e.  (Upper)  Internal  jugular  vein 

cut  off. 

e.    (Lower)  Bronchi. 

/.    Arytenoid  cartilage. 

g.   Subclavian  artery. 

ft.   Common  carotid  artery. 

».    External       "  " 

l'.    Internal        " 

Jt.    Base  of  cranium. 

m.  (Upper)  First  cervical  verte- 
bra. 

TO.  (Lower)  Arytenoideus  muscle. 

n.  Pharynx  cut  off  from  upper 
attachments. 

O.    Epiglottis. 

p.  Hyoid  bone. 

q.   Thyroid  cartilage. 


r,    Cricoid  cartilage. 
S.    Thyroid  gland. 
U.  Thyro-cricoid  muscle. 
V.  Cervical  vertebrae. 
x  Sf  y.  Muscles  of  neck 
z.  Innominate  artery 


FIG.  ii. 

ARTERIES  AND   VEINS  OP  THE 
ANTERIOR  PORTION  OP  THE  NECK. 

Vessels  of  the  neck,  showing 
those  in  danger  of  being  severed 
in  making  artificial  opening  into 
the  larynx  and  trachea,  and  their 
connections. 

a.  Trachea. 

b.  Cricoid  cartilage. 
C.   Thyroid  cartilage. 

d.  Thyroid  gland. 

e.  Crico-thyroid  membrane. 

f.  Thyro-hyoid  membrane. 

g.  Hyoid  bone. 
ft.  Aorta. 

i.    Innominate  artery. 

i.  Common  carotid  artery. 

Jfc.  Superior  thyroid  artery. 

I.    Anterior  jugular  vein. 

m.  Crico-thyroid  artery. 

n.  Internal  jugular  vein. 

O.   Thyroid  plexus. 

p.  Right  inferior  jugular  vein. 

q.  Left  inferior  jugular  vein. 

r.   Crico-thyroid  vein. 

S.   Superior  thyroid  vein. 

t.   Middle  thyroid  vein. 

U.  External  jugular  vein. 

V.   Subclavian  vein. 

x.  Right  and  left  innominate  vein, 

y.  Superior  vena  cava. 


'PJate    VII. 


... 


Sajous,  Pinx.it. 


W.H.BuTLE/r  Acr LITH.PHILA, 


PHYSIOLOGY.  309 

clarionet  is  caused  to  vibrate  by  the  breath  of  the  player. 
The  pitch  of  the  note  produced  depends  upon  the  tension 
of  the  vocal  bands,  which  in  turn  depends  upon  the  degree 
of  displacement  backward  of  the  arytenoid  cartilages,  induced 
by  the  action  of  the  thyro-cricoid  muscles  upon  the  cricoid 
cartilage.  If  now  another  note  is  to  be  sounded,  say  one 
tone  higher,  the  thyro-cricoid  muscles  contract  a  little  more, 
increasing  the  tension  of  the  bands  in  proportion.  If,  on 
the  contrary,  a  lower  note  is  to  be  given,  the  thyro-arytenoid 
muscles  contract  and  approximate  the  vocal  processes  of 
,  the  arytenoid  cartilages  to  the  thyroid  cartilage,  while  the 
thyro-cricoid  muscles  relax  to  an  equal  degree.  Although 
their  tension  is  decreased,  the  vocal  bands  are  thus  held 
steadily  between  the  two  antagonistic  sets  of  muscles,  and  a 
note  can  be  prolonged  without  change  of  pitch  as  long  as 
the  expiratory  breath  lasts. 

For  the  clear  production  of  the  voice,  absolute  integrity 
of  the  vocal  bands  and  muscles  must  exist.  A  slight  con- 
gestion of  the  mucous  membrane  of  the  former,  by  thick- 
ening their  edges,  interferes  with  their  proper  vibration, 
and  hoarseness  is  produced,  while  great  congestion  may 
cause  complete  loss  of  the  voice,  by  rendering  vibration 
impossible;  again,  their  approximation  and  vibration  may 
be  prevented  by  the  presence  of  a  tumor  or  paralysis  of 
some  of  the  adductor  muscles.  Inflammation  of  the  muscles 
may  also  compromise  greatly  the  production  of  voice 
through  the  paresis  induced  by  the  inflammatory  infil- 
tration. 


CHAPTER  XXII. 

LAEYNGOSCOPY. 

LARYNGOSCOPY  is  the  term  applied  to  the  optical  exami- 
nation of  the  larynx.  This  is  accomplished  with  the  assist- 
ance of  the  laryngeal  mirror,  sometimes  called  "  laryngos- 
cope," and  either  natural  or  artificial  light.  The  laryngeal 
mirror  employed  in  this  country  consists  of  a  plain,  round 
mirror,  varying  in  diameter  from  one-half  to  one  inch,  and 
mounted  in  a  metallic  frame.  To  the  edge  of  this  frame,  a 
strong  wire  stem,  about  four  inches  in  length  is  attached, 
at  an  angle  of  about  120° ;  this,  in  turn,  is  either  securely 

Fig.  76. 


Laryngeal  mirror. 

connected  with  a  small  handle,  or  left  free  so  as  to  be  intro- 
duced at  will  into  a  universal  handle,  an  ordinary  handle 
perforated  longitudinally,  and  furnished  near  its  extremity 
with  a  thumb-screw,  which  can  be  tightened  down  upon 
the  stem  when  this  is  introduced.  Different  sizes  of  laryn- 
geal mirrors  are  furnished,  and  are  numbered  according 
to  their  size,  No.  1  representing  the  largest  size  mirror,  one 
inch  in  diameter;  No.  2,  the  second  in  size,  being  three 
quarters  of  an  inch  in  diameter,  and  No.  3,  which  is  only 
one-half  inch  in  width.  When  possible,  the  largest  mirror 
should  be  used,  its  surface  reflecting  a  greater  number  of 
luminous  rays,  and,  therefore,  illuminating  the  parts  more 
(310) 


LARYNGOSCOPY.  311 

brightly.  In  some  cases,  however,  the  smaller  mirrors  can 
alone  be  used,  their  limited  diameter  enabling  them  to  be 
introduced  without  touching  the  surrounding  parts.  In  chil- 
dren, for  instance,  a  mirror  larger  than  No.  2  can  but  very 
seldom  be  used,  the  narrowness  of  the  pharyngeal  cavity 
otherwise  causing  the  walls  to  come  in  contact  with  the 
circumference  of  the  frame. 

We  have  seen  in  the  chapter  on  anatomy,  that  in  order 
to  completely  uncover  the  laryngeal  cavity,  it  is  necessary 
to  raise  the  epiglottis  from  its  semi-recumbent  position, 
and  that  the  glosso-epiglottic  ligament  unites  it  to  the 
tongue.  Protrusion  of  the  latter,  therefore,  causes  elevation 
of  the  epiglottis,  the  parts  behind  and  below  it  thus  be- 
coming visible.  For  a  laryngeal  examination,  this  is  indis- 
pensable. The  tongue  must  not  only  be  protruded,  but  it 
must  be  held  so,  either  by  the  patient  or  the  physician. 
When  the  patient  is  first  seen,  he  is  frequently  inclined 
to  withdraw  the  head  when  the  mirror  is  being  introduced, 
but  as  soon  as  it  has  been  applied  once  or  twice,  the  slight 
degree  of  apprehension  leaves  him,  and  he  holds  his  head 
steadily.  In  the  first  examinations,  therefore,  it  is  preferable 
to  hold  his  tongue  for  him,  a  clean  towel  being  interposed 
between  fingers  and  tongue.  Later  on,  he  is  shown  how  to 
grasp  the  organ  between  his  index  finger  and  thumb  to 
hold  it,  not  to  pull  it,  lest  the  fra3imm  be  wounded  by  the 
lower  incisors.  He  should  use  his  right  hand  if  the  mirror 
is  held  in  the  right  hand  by  the  observer,  or  vice  versa,  the 
object  being  to  avoid  the  impediment  which  the  patient's 
hand  would  offer  were  they  both  on  the  same  side  of  the 
mouth.  The  tongue  being  withdrawn,  the  next  step  is  to 
adjust  the  light  so  that  the  central  rays  will  impinge  upon 
the  spot  just  above  the  level  of  the  surface  of  the  tongue. 
The  laryngeal  mirror,  held  like  a  penholder,  is  then  exposed 


512 


LARYNGOSCOPY. 


over  the  light  a  couple  of  seconds,  with  the  glass  surface 
downward.  This  is  to  heat  it  slightly,  so  as  to  avoid  the 
condensation  of  the  watery  portion  of  the  breath  which 
would  take  place  upon  it,  if  it  were  cold,  thus  blurring  it 
completely.  Its  posterior  surface  is  then  placed  upon  the 
back  of  the  other  hand  so  as  to  ascertain  that  it  is  not 


The  laryngeal  mirror  in  position. 

sufficiently  hot  to  burn  the  patient,  after  which  the  mirror 
is  quickly  introduced  into  the  mouth,  the  long  axis  of  the 
instrument  being  first  perpendicular,  then  brought  to  the 
horizontal  by  raising  the  handle  as  the  instrument  is  ad- 
vanced in  the  oral  cavity.  In  this  manner  the  surface  of 
the  mirror  is  in  relation  with  the  surface  of  the  hard  palate 


LARYNGOSCOPY.  313 

until  in  position,  thus  greatly  diminishing  the  likelihood  of 
touching  the  base  of  the  tongue,  and  avoiding  gagging  and 
nausea.  As  soon  as  the  uvula  is  reached,  the  back  of  the 
mirror  is  placed  against  it,  and  it  is  pushed  upward  and 
backward,  adjusting  at  the  same  time  the  surface  of  the 
glass  (by  depressing  the  handle  slightly)  so  as  to  cause  the 
image  of  the  laryngeal  cavity  to  appear  in  it.  If  no  ob- 
struction is  presented,  an  unruly  or  over-sensitive  tongue,  a 
depressed  epiglottis,  etc.,  the  upper  border  and  interior  of  the 
larynx  and  the  upper  portion  of  the  interior  of  the  trachea 
will  be  seen,  and  if  the  patient  be  breathing  quietly,  the 
edge  of  the  vocal  bands  will  appear  in  the  abducted  posi- 
tion, looking  like  little  white  shelves,  about  three-quarters 
of  an  inch  long,  which  are  approximated  at  one  end  and 
diverge  from  above  downward  (in  the  mirror)  forming  a  V 
upside  down.  If  now  the  patient  is  requested  to  say  ah,  all, 
the  vocal  bands  will  be  seen  to  rotate  suddenly  upon  their 
anterior  attachment  and  come  together,  the  A  being  replaced 
by  two  parallel  bands  with  a  slight  slit  between  them.  Their 
width  will  appear  greater  than  when  they  were  separated, 
the  greater  part  of  their  surface  being  then  hidden  under  the 
ventricular  bands,  their  edges  merely  appearing. 

As  represented  in  the  mirror,  the  image  appears  to  the 
observer  as  if  he  were  standing  behind  the  larynx  and 
looking  into  it,  this  being  in  reality  the  position  of  the 
mirror,  which  also  stands  behind  and  above  the  larynx. 
The  observer  sees  it,  therefore,  as  if  he  were  in  the  mirror's 
place.  The  anterior  commissure  or  the  apex  of  the  A  formed 
by  the  abducted  vocal  bands  being  anterior  in  relation  to 
the  throat,  it  is  therefore  seen  in  the  upper  portion  of  the 
mirror,  while  the  widest  portion  of  the  \_  is  near  its  lower 
margin. 

Beginning  at  the  upper  portion   of  the  image,   the   first 


LAIttNGOSCOPY. 

object  seen  is  the  epiglottis,  its  curled  border  varying 
greatly  in  shape  with  different  individuals,  but  generally 
presenting  the  shape  of  a  Cupid's  bow,  with  the  concavity 
downward.  Its  color  is  yellowish  pink,  with  arborescent 
blood-vessels  strewn  over  its  surface.  Starting  from  each 
side  and  curving  inwardly  as  they  advance,  are  the  ary-epi- 
glottic folds,  which  form  the  upper  border  of  the  laryngeal 
aperture,  and  are  united  posteriorly  by  the  inter-arytenoid 
fold,  formed  by  the  arytenoideus  muscle  and  its  overlying 
membrane.  At  the  point  of  junction  of  the  inter-arytenoid 
fold  with  the  ary-epiglottic  fold  on  each  side,  may  be  seen  a 
little  knob,  formed  by  the  diminutive  cartilage  of  Santorini, 
which  surmounts  the  apex  of  the  arytenoid  cartilage.  A 
little  higher  up  towards  the  epiglottis,  another  but  some- 
what larger  knob  may  be  seen  on  each  side,  this  being  the 
eminence  caused  by  the  cartilage  of  Wrisberg,  a  perpendicular 
strip  of  cartilage,  which  seems  to  support  the  walls  of  the 
larynx.  The  four  knobs  are  enclosed  in  the  ary-epiglottic 
folds,  which  are  rather  more  pink  in  color  than  the  epi- 
glottis, and  devoid  of  arborescent  vessels. 

Going  deeper  into  the  laryngeal  cavity,  we  now  come 
to  the  ventricular  lands,  whose  posterior  insertions  about 
correspond  with  the  interval  between  the  cartilages  of  Wris- 
berg  and  Santorini.  Their  anterior  commissure  is  hidden 
by  a  more  or  less  prominent  nodule,  the  cushion  of  the  epi- 
glottis, which  projects  from  the  internal  surface  of  the  latter, 
and  serves,  when  it  is  depressed,  to  close  what  interval  may 
be  left  between  them.  The  ventricular  bands  generally 
present  about  the  same  color  as  the  ary-epiglottic  folds, 
which  surround  them. 

Below  the  ventricular  bands  and  parallel  with  them,  appear 
the  vocal  bands,  contrasting  by  their  bright  white  color,  with 
the  pink  hue  of  the  surrounding  parts.  Their  anterior  com- 


OBSTACLES   TO   LARYNGOSCOPY.  315 

missure  is  also  generally  hidden  by  the  cushion  of  the  epi- 
glottis, while  the  posterior  extremities  are  attached  imme- 
diately below  the  cartilages  of  Santorini.  If  the  mirror  is 
slightly  rotated  on  its  axis  and  turned  somewhat,  a  dark 
recess  will  be  seen  between  the  ventricular  band  and  the 
vocal  band  of  the  side  examined;  this  is  the  aperature  of 
the  vent  fide  of  the  larynx.  Below  the  vocal  bands,  the 
tracheal  rings  are  brought  to  view,  five  or  six  being  gen- 
erally seen,  while  in  some  cases  the  entire  trachea  and  a 
small  portion  of  the  right  bronchus  may  be  examined. 

OBSTACLES   TO   LARYNGOSCOPY. 

In  many  cases,  a  laryngoscopic  examination  is  accom- 
panied by  great  difficulty.  A  peculiar  conformation  of  the 
epiglottis,  enlarged  tonsils,  an  over-sensitive  throat,  etc., 
are  obstacles  which  often  have  to  be  overcome  before  a 
satisfactory  examination  can  be  conducted.  An  overhanging 
epiglottis  is  the  most  frequent  cause  of  interference;  the 
depression  may  be  slight,  and  cover  but  a  small  part  of 
the  anterior  portion  of  the  laryngeal  cavity,  or  it  may  be 
so  great  as  to  allow  only  its  posterior  border  to  appear.  In 
these  cases  a  satisfactory  examination  can  only  be  obtained 
by  raising  the  epiglottis  while  the  mirror  is  in  position. 
Several  instruments  have  been  invented  for  the  purpose, 
but  they  can  very  seldom  be  used  without  causing  the 
patient  to  retch  and  gag. 

The  application  of  a  four  per  cent,  solution  of  cocaine 
to  the  posterior  surface  of  the  epiglottis,  however,  renders 
its  manipulation  possible,  and  any  curved  probe,  or  the 
instrument  shown  in  Fig.  69,  turned  downward,  may  be 
employed  to  raise  it  against  the  base  of  the  tongue.  The 
probe  is,  of  course,  held  with  the  left  hand  if  the  mirror  is 
held  with  the  right.  Two  or  three  successive  applications 


31G  LARYNGOSCOPY. 

of  cocaine,  at  a  couple  of  minutes'  interval,  are  sometimes 
necessary  to  render  the  epiglottis  completely  asensitive. 

An  over-sensitive  pharynx  is  probably  the  obstacle 
most  frequently  met  with.  The  mirror  is  hardly  in  the 
mouth  but  that  the  patient  begins  to  manifest  all  the 
symptoms  of  a  coming  emesis,  a  result  which  occasionally 
takes  place.  A  spray  of  cocaine,  however,  is  very  effective 
in  mastering  superficial  sensitiveness.  If  an  atomizer  be 
not  at  hand,  it  can  be  applied  with  the  brush  or  cotton 
pledget,  the  brunt  of  the  application  being  made  over  the 
base  of  the  tongue.  After  two  or  three  examinations  with 
cocaine,  the  parts  become  much  more  tolerant  and  the 
laryngoscope  can  generally  be  borne  without  trouble.  When 
cocaine  cannot  be  had,  gargling  with  ice-water,  a  thirty- 
grain  dose  of  bromide  of  potassium,  morphia,  etc.,  will 
sometimes  succeed  in  allaying  the  irritability  for  a  short 
wrhile.  In  some  cases  it  is  utterly  impossible  to  examine 
the  throat  without  the  assistance  of  cocaine.  When  this 
agent  cannot  be  had,  training  the  parts  to  the  presence  of 
a  foreign  body  by  the  introduction,  two  or  three  times  a 
day  for  a  week  or  so,  of  the  handle  of  a  spoon  or  some 
other  blunt  object,  will  generally  succeed  in  diminishing 
their  sensibility  sufficiently  to  render  an  examination  pos- 
sible. 

An  elongated  uvula  sometimes  interferes  with  the  ex- 
amination, by  bending  anteriorly,  then  upward,  around  the 
lower  margin  of  the  mirror,  through  the  pressure  exerted 
by  the  latter  upon  it  and  the  underlying  pharyngeal  wall. 
This  can  be  overcome,  in  most  cases,  by  quickly  passing 
the  mirror  below  the  tip  of  the  uvula,  then  raising  the  latter 
upon  its  metallic  or  posterior  surface  until  the  proper  posi- 
tion for  the  instrument  is  reached.  Enlarged  tonsils  some- 
times prevent  the  introduction  of  the  mirror  in  the  pharyn- 


OBSTACLES   TO   LARYNGOSCOPY.  ,'517 

geal  space,  rendering  the  use  of  a  smaller  mirror  necessary. 
An  unruly  tongue  occasionally  renders  a  view  of  the  mirror, 
when  this  is  in  position,  almost  impossible.  It  should  in 
that  case  be  held  by  the  observer,  a  tongue-depressor  being- 
used  in  connection  with  the  towel  employed.  The  handle 
of  the  instrument  can  be  held  between  the  thumb  and  the 
tongue,  while  the  index  finger  under  the  latter  serves  as  the 
supporting  point.  Care  should  be  taken  not  to  exert  pres- 
sure on  the  portion  of  the  tongue  lying  on  the  lower  teeth, 
lest  the  fra3num  be  cut  or  crushed. 


CHAPTER   XXIII. 

INSTRUMENTS    USED    IN    CLEANSING  AND   MEDICATING  THE  LARYNX. 

WHEN  cleansing  of  the  laryngeal  surfaces  is  indicated, 
this  being  by  no  means  as  frequently  the  case  as  in  diseases 
of  the  nose  or  pharynx,  Sass'  laryngeal  tube  (Fig.  17)  may 
be  employed.  It  is  useful  to  remove  masses  of  purulent 

Fig.  78. 


Lentz's  atomizer. 


secretion  which  adhere  tenaciously  to  the  mucous  membrane. 
For  general  purposes,  however,  an  atomizer,  such  as  that 
shown  in  Fig.  19,  with  a  tip  turned  downward,  or  the  instru- 
ment represented  in  the  annexed  cut,  which,  notwithstanding 
its  single  bulb,  produces  a  continuous  flow,  is  preferable,  the 
spray  being  much  lighter  and  presenting  no  mechanical  force 
to  irritate  the  parts. 
(318) 


ATOMIZERS.  319 

When  an  atomizer  is  to  be  used,  the  tongue  should  be 
withdrawn  and  held  by  the  patient,  so  as  to  raise  the 
epiglottis  and  uncover  the  larynx  as  much  as  possible.  The 
bottle  is  held  with  one  hand,  while  the  other  is  used  to  work 
the  bulb,  unless  an  air-compressor  be  employed,  when  the 
tongue  can  be  held  by  the  physician,  so  as  to  maintain  the 
head  in  a  steady  position.  The  tube  being  introduced  into 
the  mouth,  the  patient  is  directed  to  take  long  breaths  and 
to  make  his  respiration  as  soft  as  he  can ;  this  is  to  diminish 
as  much  as  possible  the  resistance  which  the  respiratory 
current  presents  to  the  spray,  thus  preventing  its  access  to 
the  larynx  during  expiration.  During  inspiration,  the  pene- 
tration of  the  spray  into  the  trachea  being  reduced  to  a 
minimum,  the  liability  to  cough  is  decreased.  "When  it  is 
desirable  to  reach  as  much  of  the  vocal  bands  as  practicable, 
the  patient  is  requested  to  make  a  sound,  wThich  will  cause 
the  bands  to  come  together,  exposing  their  entire  surface. 
A  couple  of  minutes,  at  the  longest,  are  sufficient,  in  most 
cases,  to  thoroughly  cleanse  the  laryngeal  surfaces,  or  at  least 
to  so  soften  the  mucoid  or  muco-purulent  masses  as  to  cause 
them  to  be  easily  expectorated. 

Impediments  are  often  encountered  which  render  the  use 
or  the  atomizer  very  difficult.  A  thick,  rebellious  tongue, 
an  over-sensitive  throat,  retching,  caused  by  the  least  ap- 
proximation of  the  point  of  the  tube  to  the  papilla?  at  the 
base  of  the  protruded  tongue,  and  an  overhanging  epiglottis, 
are  some  of  the  difficulties  met  with.  To  subdue  a  rebel- 
lious tongue,  the  tongue  depressor  may  be  used  to  advan- 
tage, the  organ  (held  by  the  patient)  being  forced  down  in 
the  centre.  Over-sensitiveness  of  the  throat  and  the  base  of 
the  tongue  can  be  much  reduced  by  swabbing  the  parts  with 
a  four  per  cent,  solution  of  cocaine,  the  anesthesia  lasting 
sufficiently  long  to  enable  the  operator  to  treat  the  parts 
effectively. 


320  INSTRUMENTS   USED   IN   TREATING   THE   LARYNX. 

For  the  application  of  solutions  in  small  quantities,  I  prefer 
the  cotton  pledget  to  either  the  sponge  or  the  brush ;  it  is 
cleanly  and  soft,  and  can  be  thrown  away  after  each  applica- 
tion. The  only  feature  which  somewhat  militates  against  its 
use,  is  the  liability  of  small  films  to  become  detached  and  to 
cause  irritation  in  the  larynx  by  remaining  there.  This  can 
be  obviated,  however,  by  passing  the  cotton  pledget  over  the 
light  used  for  illumination,  which  will  cause  what  films  are 
not  closely  adherent  to  the  pledget  proper  to  burn  off. 

I  have  found  the  instrument  shown  in  Fig.  22  (which  is 
shown  in  Fig.  79  in  the  position  it  occupies  when  held  in 


Fig.  79 


Laryngeal  colton  forceps  in  position. 

the  larynx)  most  convenient.  Any  size  of  cotton  pledget, 
folded  as  described  on  page  45,  may  be  used  with  it,  so 
that  a  large  as  well  as  a  small  surface  can  be  thoroughly 
treated. 

The  manipulation  of  this  instrument  in  the  larynx  is  much 
the  same  as  for  the  posterior  nares.  The  laryngoscopic 
mirror,  held  with  the  left  hand,  should  be  used  to  guide 
the  applications  ;  the  forceps  being  introduced  with  its  curved 
surface  lying  horizontally,  is  quickly  turned  on  its  axis,  the 
tip  being  over  the  laryugeal  cavity.  The  point  to  be  touched 


POWDER  INSUFFLATORS.  321 

is  then  well  noted  in  the  mirror,  and  the  tip  is  suddenly  low- 
ered and  applied  to  the  desired  spot,  the  forceps  being  then 
quickly,  but  gently,  withdrawn.  This  manipulation  presents 
some  difficulty  at  first,  but  this  is  overcome  after  repeated 
trials.  When  the  application  is  to  be  made  to  a  larger 
area,  or  to  the  entire  surface  of  the  larynx,  a  large  piece  of 
cotton  is  used,  and  when  the  pledget  is  introduced  into  the 
laryngeal  cavity,  it  is  left  there  an  instant,  when  muscular 
contraction  will  squeeze  and  deplete  it  of  its  solution.  Cotton 
pledgets  should  at  no  time  be  full  of  the  fluid  used,  lest  the 
latter  run  down  in  a  stream  along  the  internal  wall  of  the 
trachea  and  produce  considerable  distress  and  coughing. 

For  the  application  of  powders,  the  scoop  insufflator,  shown 
in  Fig.  25,  with  the  tip  turned  downward,  is  the  most  con- 
venient instrument  when  a  fixed  quantity  is  to  be  employed. 
The  manipulation  is  the  same  as  for  the  atomizer,  the  tongue 
being  held  out  by  the  patient,  so  as  to  raise  the  epiglottis, 
and  the  mirror  being  used  to  guide  the  application.  When 
the  powder  is  to  be  applied  to  or  above  the  vocal  bands,  the 
patient  is  requested  to  make  a  sound,  and  the  powder  being 
blown  out  just  as  he  does  so,  the  agent  used  covers  the 
supra-glottic  surfaces  without  falling  into  the  trachea,  while 
the  vocal  bands  are  thoroughly  covered.  When  the  powder 
is  to  be  distributed  evenly  over  the  entire  surface,  this  can 
be  done  by  dividing  the  single  insufflation  into  a  series  of 
small  puffs,  changing  the  direction  of  the  tip  of  the  insuf- 
flator each  time,  and  holding  it  as  high  as  possible  over  the 
larynx.  The  mucous  membrane  is  thus  covered  with  a  thin 
film  of  the  remedy.  When  a  spot  of  ulceration  is  to  be 
treated  and  the  powder  is  to  be  limited  to  it,  the  tip  of  the 
insufflator  should  be  approached  as  closely  as  possible  over 
it,  and  a  slight  puff  will  cover  it  thoroughly. 

For  the  insufflation  of  remedies  not  requiring  exact  dosage, 

21 


322  INSTRUMENTS   USED   IN  TREATING  THE  LARYNX. 

sucli  as  iodoform,  Dr.  A.  H.  Smith's  insufflator  (Fig.  26)  is 
by  far  the  most  convenient,  the  tip  being  turned  downward. 
The  two  hands  being  necessary  for  its  manipulation,  the 
mirror  cannot  be  used;  but  as  the  remedies  employed  in 
that  manner  are  diffused  over  the  entire  laryngeal  surface, 
the  assistance  of  that  instrument  is  not  required. 

.Steam  inhalations  are  of  advantage  in  the  treatment  of 
laryngeal  affections  when  the  patient  can  remain  at  home. 
If,  on  the  contrary,  he  is  obliged  to  go  in  the  open  air,  they 
are  more  hurtful  than  beneficial,  offering  positive  danger 
sometimes,  and  especially  in  cases  of  subacute  laryngitis. 
The  sudden  transition  to  which  the  inflamed  parts  are  sub- 
jected, by  the  exposure  to  widely  different  degrees  of  tem- 
perature, readily  explain  the  manner  in  which  an  acute 
inflammation  can  be  brought  about. 

A  popular  method  of  administering  steam  inhalations  is 
to  half  fill  a  pitcher  with  warm  water,  using  it  pure  or 
medicated  with  some  diffusible  agent,  and  to  surmount  the 
vessel  with  a  towel  folded  cone-shape,  with  the  apex  of  the 
cone  turned  upward.  The  patient  having  introduced  his 
mouth  and  nose  in  the  opening  formed  above,  inhales  deeply 
as  long  as  an  appreciable  amount  of  steam  is  generated.  The 
inhaler  described  on  page  50,  and  shown  in  Fig.  28,  presents 
many  advantages  for  the  administration  of  pure  or  medi- 
cated steam.  One-half  pint  of  water  being  poured  into  the 
can,  this  is  placed  on  the  stove  or  on  an  alcohol  lamp  until 
the  water  is  heated  to  the  desired  temperature,  this  being 
noted  on  the  thermometer  which  protrudes  through  the 
stopper.  If  a  medicinal  agent  is  used,  it  is  dropped  in 
through  the  mouth  of  the  instrument,  the  rubber  stopper 
being  then  adjusted  so  as  to  close  the  aperture  hermetically. 
The  patient  should  then  introduce  the  mouthpiece,  which  is 
covered  with  rubber  tubing  to  prevent  burning  of  the  lips, 


STEAM   ATOMIZER. 


323 


into  his  mouth  and  breathe  through  it,  the  inspiratory  cur- 
rent being  drawn  from  the  instrument  through  the  lower 
valve,  while  the  expired  column  of  air  is  driven  out  into 
the  surrounding  atmosphere  through  the  upper  valve.  This 
can  be  continued  for  two  or  three  minutes,  or  more,  if  the 
patient  is  not  fatigued.  For  office  practice,  pieces  of  rubber 
tubing,  an  inch  long,  can  be  kept  on  hand  so  as  to  supply  a 
new  mouthpiece  covering  for  each  patient.  This  is  not 
only  a  measure  of  cleanliness,  but  also  of  prudence. 

Another  instrument  used  for  administering  steam  inhala- 
tions, is  the  steam  atomizer  shown  in  Fig.  80.    The  steam 


Codman  &  ShurtlefTs  modification  of  Siegle's  steam  atomizer. 

is  formed  in  a  little  boiler  supported  over  an  alcohol  lamp, 
and  while  passing  out  through  a  horizontal  glass  tube,  over 
the  end  of  another  but  perpendicular  tube  which  dips  in 
the  medicament  used,  it  produces  a  vacuum  in  the  latter 
which  causes  the  medicinal  agent  to  ascend  and  to  mix 
with  the  steam  current.  It  is  a  very  convenient  instrument, 
but  is  rather  difficult  to  keep  in  perfect  order.  It  is  employed 
in  the  same  manner  as  the  preceding. 


CHAPTER  XXTY. 

THERAPEUTICS   OF   THE   LARYNX. 

CLEANSING  of  the  laryngeal  mucous  membrane  is  of  great 
importance  before  the  application  of  local  remedies,  in  chronic 
catarrhal  affections.  In  acute  affections,  it  but  stimulates 
the  inflammatory  process  and  should  therefore  be  avoided. 
In  chronic  laryngitis,  as  well  as  in  the  laryngeal  manifesta- 
tions of  tuberculosis  and  syphilitic  laryngitis,  it  forms  a 
prominent  part  of  the  treatment,  not  only  relieving  the  sur- 
faces of  the  secretions  which  prevent  the  contact  of  the 
remedy  used,  but  also  exerting  a  marked  influence  in  limit- 
ing the  ulcerative  process. 

In  the  treatment  of  laryngeal  affections,  a  greater  amount 
of  circumspection  is  necessary  in  choosing  cleansing  instru- 
ments than  for  the  nasal  cavities  and  pharynx.  If  the 
presence  of  chronic  disease,  accompanied  by  copious  dis- 
charge, renders  their  use  necessary,  not  only  to  wash  away 
the  discharges,  but  also  to  expose  the  mucous  surfaces  to 
the  action  of  the  more  active  agents  used  in  the  treatment, 
Sass'  laryngeal  tube  produces  the  strongest  spray,  and  is 
therefore  to  be  theoretically  preferred;  but  the  mechanical 
power  which  serves  so  well  for  the  removal  of  secretions  is 
frequently  more  than  the  inflamed  surfaces  can  bear.  The 
comparatively  large  atoms  of  fluid  act  somewhat  like  foreign 
bodies,  and  latent  inflammation  may  be  turned  into  active 
inflammation,  and  the  application,  therefore,  do  more  harm 
than  good.  Lennox  Browne,  of  London,  considers  the  use 
of  the  spray  in  the  larynx  as  unphysiological  and  foreign 
to  the  natural  function  of  the  organ.  I  am  not  pre- 
(324) 


MEDICATION.  325 

pared  to  advocate  this  opinion  in  its  entirety,  for  I  believe 
that  with  proper  choice  of  instruments  as  regards  the  density 
of  the  spray  produced,  and  a  careful  determination  of  the 
deo-ree  and  kind  of  inflammation  present,  the  atomizer  is  a 
valuable  instrument.  In  other  words,  I  consider  it  as  being 
of  great  assistance  in  the  treatment  of  laryngeal  affections, 
if  used  intelligently. 

When  a  strong  spray  such  as  Sass'  is  not  well  borne  by  the 
patient,  or  the  membrane  betokens,  by  its  diffuse  redness,  a 
subacute  inflammation  in  addition  to  the  chronic  state, 
atomizers,  such  as  those  shown  in  Figures  19  and  78,  may 
be  tried,  their  spray  being  much  lighter  and  presenting  no 
appreciable  mechanical  force.  I  have  always  been  able  to 
use  either  of  these  instruments,  even  when  a  considerable 
degree  of  subacute  congestion  existed. 

As  to  the  selection  of  the  kind  of  cleansing  solution  to 
be  used,  the  remarks  made  on  the  subject  when  speaking  of 
the  nasal  cavities,  can  be  here  repeated.  When  there  is 
profuse  discharge,  dependent  simply  upon  a  relaxation  of 
the  membrane,  its  mere  -admixture  with  an  alkaline  liquid 
will  be  sufficient  to  wash  it  off.  If  the  secretion  is  thick, 
however,  a  solvent  will  facilitate  its  separation  from  the 
seat  of  production.  Bicarbonate  of  sodium  and  biborate 
of  sodium  (gr.  iv-?j)  or  the  solutions  on  pages  75  and  118 
may  be  used,  according  to  indications. 

MEDICATION. 

Taking  the  solutions  usually  recommended  for  the  treat- 
ment of  nasal  affections  as  a  basis,  larvngeal  solutions  should 

V 

be  at  least  twenty-five  per  cent,  weaker,  lest  irritation  be  pro- 
duced. The  proportions  recommended  for  the  nose,  in  this 
work,  however,  are  weaker  than  those  generally  employed, 
and  astringents,  stimulants,  alteratives,  and  sedatives  can 


326  THERAPEUTICS  OF  THE  LARYNX. 

be  used  in  the  proportions  given  in  the  chapter  on  thera- 
peutics of  the  nasal  cavities,  the  drugs  being  also  the  same. 
In  the  choice  of  agents  to  act  as  diluents  with  more  potent 
drugs  in  the  form  of  powder,  preference  should  be  given  to 
substances  capable  of  being  easily  dissolved  in  the  laryngeal 
mucus.  Bismuth,  which  is  frequently  recommended,  does  not 
possess  this  property,  and  remains  a  long  while  on  the  spot 
to  which  it  was  applied,  acting  in  a  certain  manner  like  a 
foreign  body,  producing  cough  and  retching,  and,  conse- 
quently, irritation.  Pulverized  acacia  is  probably  the  most 
satisfactory  agent  we  possess  for  the  purpose;  it  is 
bland  and  soothing,  and  covers  the  membrane  with  a 
uniform  coat  which  separates  it  from  the  air  current  for 
awhile,  during  which  the  active  principle  of  the  powder  is 
absorbed.  Escharotics  are  also  used  in  the  larynx,  chromic 
acid  being  manipulated  with  the  greatest  ease  and  at  the 
same  time  being  very  effective. 


CHAPTER  XXV. 

DISEASES    OF   THE   LARYNX. 
SUBACUTE     LARYNGITIS 

(Synonyms  : — Simple  Catarrhal  Laryngitis  ;  Catarrhal  Laryngitis ; 
Erythematous  Laryngitis.) 

Etiology. — Exposure  to  cold  is  the  most  frequent  cause  of 
subacute  laryngitis :  a  sudden  change  from  heat  to  cold,  such 
as  going  from  a  warm  room  into  the  open  air  insufficiently 
clothed,  exposure  to  draughts,  wet  feet,  etc.  It  is  for  that 
reason  very  common  during  fall,  the  system  being  relaxed 
by  the  preceding  warm  weather  and  therefore  more  prone 
to  become  influenced.  Local  irritation  by  irritating  vapors, 
tobacco  smoke,  dust,  etc.,  are  also  frequent  causes.  It  is 
sometimes  due  to  over-exertion  of  the  voice,  in  loud  sing- 
ing, for  instance,  when  the  singer  has  had  no  training  in  the 
proper  use  of  his  vocal  organ.  It  is  often  present  in  army 
officers,  after  manoeuvre  or  drilling.  Subacute  laryngitis  is 
a  frequent  complication  of  acute  rhinitis  and  occasionally 
of  acute  bronchitis.  Persons  leading  sedentary  lives  are 
more  subject  to  it  than  those  accustomed  to  out-door  exer- 
cise. Rheumatic  and  scrofulous  individuals  seem  to  be  more 
predisposed  to  it  than  others.  It  may  also  occur  as  a  symp- 
tom of  scarlatina,  measles,  and  the  exanthemata. 

Pathology. — In  subacute  laryngitis  the  inflammatory  pro- 
cess is  confined  to  the  superficial  layers  of  the  mucous  mem- 
brane, and  does  not  at  first  involve  the  submucous  tissue 
and  sometimes  the  muscles,  as  in  acute  laryngitis.  After  it 
has  lasted  for  some  time,  however,  it  may  penetrate  these 
parts,  the  inflammatory  infiltration  spreading  to  them. 

(327) 


328  DISEASES   OF   THE   LAKYNX. 

Symptoms. — The  first  symptom  usually  experienced,  is  a 
pricking  sensation,  as  if  a  pin  were  sticking  in  the  throat. 
Slight  chilliness  may  occur,  but  in  the  majority  of  cases  it 
does  not.  Hacking  is  indulged  in  to  relieve  the  larynx  of 
a  supposed  foreign  element  which  cannot  be  dislodged.  The 
voice  soon  becomes  hoarse,  and  a  slight  burning  pain  is  ex- 
perienced, which  extends  sometimes  along  the  pharynx. 
Slight  dyspnoea  is  present  in  most  cases,  and  is  sometimes 
the  most  annoying  feature  of  the  trouble.  As  the  case 
advances,  the  hoarseness  becomes  greater  and  greater  until 
the  voice  is  sometimes  entirely  lost,  the  patient  being 
obliged  to  speak  in  a  whisper.  Deglutition  is  at  times 
quite  painful.  There  is  usually  a  coarse,  barking  cough, 
which  is,  after  a  few  days,  accompanied  by  expectoration. 
This  expectoration,  at  first  gluey  and  viscid,  soon  assumes 
a  muco-purulent  character,  and  becomes  sufficiently  purulent 
in  some  cases  to  cause  apprehension  in  the  belief  that  the 
lungs  are  seriously  involved,  thoracic  pains,  caused  by  the 
muscular  exertion  in  coughing,  serving  to  increase  the  fears 
of  the  patient. 

Examined  with  the  laryngeal  mirror,  the  entire  larynx  ap- 
pears congested,  the  ventricular  bands  and  inter-arytenoid  com- 
missure appearing  especially  red.  The  vocal  bands  are  more 
or  less  congested  also,  and  small  vessels  are  distinctly  seen 
coursing  over  them.  The  epiglottis  usually  takes  part  in 
the  general  inflammation,  arborescent  vessels  and  diffuse 
redness  covering  its  anterior  and  posterior  surfaces. 

Prognosis. — The  prognosis  of  subacute  laryngitis  is  gen- 
erally favorable,  but  it  may  be  suddenly  developed  into 
the  acute  affection  and  assume  formidable  proportions.  Its 
duration  is  from  a  few  days  to  a  couple  of  weeks.  Fre- 
quently repeated,  subacute  laryngitis  may  conduce  to  chronic 
laryngitis. 


SUBACUTE   LARYNGITIS.  329 

Treatment. — The  most  important  requisite  in  the  treatment 
of  this  affection  is  absolute  rest.  The  use  of  the  voice,  how- 
ever slight  it  may  be,  naturally  increases  the  local  con- 
gestion, aggravating  the  symptoms.  The  patient  should 
remain  at  home,  and  avoid  atmospheric  transitions  such  as 
going  from  one  room  to  another  of  a  different  temperature, 
sitting  by  an  open  window,  etc.  Frequently,  an  attack  of 
subacute  laryngitis  can  be  suddenly  cut  short  by  a  deriva- 
tive purgative,  castor  oil  being  the  most  effective;  although 
a  "popular"  remedy,  its  effects  are  some  time  so  gratifying 
that  it  should  not  be  considered  as  obsolete.  Aconite  in 
drop  doses  every  hour,  to  control  the  fever  and  diminish 
the  local  congestion,  when  administered  early,  also  succeeds 
at  times  in  checking  the  affection.  When  the  malady  has 
existed  for  some  time,  wine  of  coca,  a  wineglassful  every 
three  hours,  generally  succeeds  in  bringing  about  a  favor- 
able change  in  from  thirty-six  to  forty-eight  hours.  In  the 
subacute  laryngitis  of  actors  or  other  persons  who  have 
to  use  their  voice  extensively,  it  is  especially  beneficial,  by 
depleting  the  congested  parts  of  superabundant  blood,  and 
diminishing  the  sensitiveness  to  the  contact  of  the  air  cur- 
rents. A  fine  spray  of  a  two  per  cent,  solution  of  cocaine 
applied  alone,  also  has  a  beneficial  influence,  but  this  becomes 
much  more  marked  with  wine  of  coca  internally.  Pulverized 
cubebs,  ten  grains  every  three  hours,  is  a  favorite  remedy. 
Camphor  packed  into  a  little  glass  tube  and  inhaled,  is 
occasionally  sufficient  to  arrest  an  attack  in  the  earliest 
stages. 

I  have  not  found  local  applications  writh  brush  or  cotton 
pledget,  of  astringents,  detergents,  etc.,  of  value  in  these 
cases,  and  cannot  therefore  recommend  them.  The  me- 
chanical irritation,  even  when  powders  are  used,  does,  in 
my  opinion,  more  harm  than  good,  and  since  I  have  aban- 


330  DISEASES    OF   THE   LAKYNX. 

doned  them  and  resorted  to  general  treatment,  I  have  had 
better  results.  Morphia  is  a  remedy  of  apparent  value  in 
these  cases,  but  I  have  not  found  it  so,  the  drug  probably 
increasing,  by  checking  to  a  degree  the  intestinal  action, 
the  laryngeal  congestion. 

ACUTE   LAKYNGITIS. 

(Sy nonyms : — Acute   Catarrhal   Laryngitis ;    Acute    Catarrh   of  the 

Larynx.) 

Etiology. — Acute  inflammation  of  the  larynx  is  but  rarely 
met  with.  It  may  occur  traumatically  or  idiopathically, 
traumatic  acute  laryngitis  being  the  commoner  of  the  two. 
The  accidental  inhalation  of  hot  water  (a  frequent  occurrence 
in  children),  flame,  caustic  vapors,  etc.,  the  presence  or 
violent  extraction  of  a  foreign  body,  the  deglutition  of 
caustic  acids,  accidental  or  with  suicidal  intent,  and 
wounds  penetrating  the  laryngeal  cavity,  are  the  most 
frequent  causes  of  the  traumatic  variety,  while  the  idio- 
pathic  may  be  due  to  exposure  to  cold,  and  occur  as  a  sudden 
complication  of  an  acute  attack ;  it  may  find  its  initial  cause 
in  a  chronic  catarrhal  inflammation,  such  as  that  occurring 
in  syphilis,  presenting  itself  in  that  case  as  a  sudden  exacer- 
bation of  the  trouble. 

Pathology. — Acute  laryngitis  differs  from  the  subacute 
variety,  in  that  the  inflammatory  process,  instead  of  being 
superficial,  extends  to  the  submucous  tissue  and  to  the 
muscles.  In  traumatic  laryngitis,  inflammatory  infiltration 
takes  place  suddenly  in  the  majority  of  cases,  and  the 
dyspnoea  is  caused  by  the  mechanical  impediment  to  respi- 
ration. The  pathological  process  of  idiopathic  laryngitis 
also  culminates  in  submucous  infiltration  in  most  cases, 
but  it  is  likely  that  paralysis  of  the  motor  muscles  and 


ACUTE  LARYNGITIS.  331 

spasm,  are  elements  of  importance  in  the  production  of  the 
most  marked  symptom,  dyspnoea. 

Symptoms. — Traumatic  laryngitis,  due  to  the  inhalation  of 
steam,  fire  or  caustic  vapors,  or  the  deglutition  of  hot  water, 
usually  sets  in  at  once,  the  infiltration  of  the  submucous 
areolar  tissue  causing  marked  swelling  of  the  ary-epiglottic 
folds  and  ventricular  bands.  Dyspnoea  soon  becomes  of  such 
intensity  that  the  other  symptoms,  those  of  subacute  laryn- 
gitis, are  overlooked;  and  if  the  patient  is  not  soon  relieved 
by  one  of  the  means  indicated  under  the  head  of  treatment, 
death  by  asphyxia  is  likely  to  occur.  Acute  inflammation,  as 
a  result  of  the  presence  of  a  foreign  body,  is  generally  de- 
veloped suddenly,  some  time  after  the  object  has  been  in 
the  larynx,  the  acute  symptoms  occurring  as  a  result  of  the 
ulcerative  process  due  to  pressure;  when  the  foreign  body 
is  sharp,  however,  the  acute  symptoms  may  present  them- 
selves early,  as  a  result  of  the  solution  of  continuity  of  tissue. 
In  this  manner,  the  violent  extraction  of  a  foreign  body  and 
wounds  penetrating  the  laryngeal  cavity,  may  also  cause 
acute  laryngitis. 

Idiopathic  acute  laryngitis,  occurring  as  a  sudden  compli- 
cation of  subacute  laryngitis,  is  at  times  so  rapidly  fatal  that 
no  warning  of  the  oncoming  issue  is  given.  The  patient 
retiring  with  a  laryngeal  inflammation  just  sufficient  to  give 
rise  to  slight  hoarseness,  for  instance,  may  be  found  dead  in 
the  morning.  These  cases  are  fortunately  very  rare,  and  are 
more  likely  due  to  spasmodic  contraction  of  the  vocal  bands 
than  to  submucous  infiltration.  As  a  complication  of  syph- 
ilitic ulceration,  infiltration  sets  in  much  less  rapidly,  the 
symptoms  gradually  increasing  in  intensity. 

The  early  objective  symptoms  vary  with  the  causes;  in 
carbolic  acid  poisoning,  for  instance,  the  parts  may  at  first 
appear  white,  etc.  Soon,  however,  the  inflammatory  process 


00-!  DISEASES   OF   THE   LAEYNX. 

assumes  the  general  form,  and  the  intense  redness  of  the 
entire  larynx  is  discerned  in  the  laryngoscope.  If  the 
caustic  substance  has  only  come  in  contact  with  its  upper 
border,  the  epiglottis  and  the  ary-epiglottic  fold  may  present 
the  greatest  degree  of  congestion,  while  the  ventricular  bands 
and  the  vocal  bands  appear  comparatively  free.  As  the  case 
progresses,  the  swelling  increases,  until  the  vocal  bands 
hardly  appear  beyond  the  edge  of  the  ventricular  bands. 
The  surrounding  parts  are  almost  always  inflamed  also, 
especially  in  traumatic  laryngitis. 

Prognosis. — Acute  laryngitis,  complicated  with  oedema,  is 
usually  fatal  if  left  to  itself,  the  traumatic  variety,  unless 
very  slight,  presenting  the  greatest  danger.  Occasionally, 
the  inflammation  recedes  after  having  reached  a  certain 
height,  but  the  possibility  of  this  occurrence  should  not 
influence  the  treatment. 

Treatment. — The  necessity  of  acting  promptly  is  self-evident. 
The  danger  being  due  to  infiltration,  and  thus  causing  swell- 
ing and  obstruction  to  respiration,  the  first  step  is  to  ascer- 
tain, by  means  of  the  laryngoscope,  the  degree  of  infiltration. 
The  respiration  should  not  be  taken  as  a  criterion,  as  the 
oedema  may  be  quite  severe  in  the  upper  part  of  the  larynx 
at  first,  without  presenting  much  obstruction  to  the  passage 
of  air,  and  suddenly  kill  the  patient  by  obstructing  the  laryn- 
geal  aperture  unexpectedly.  If  the  degree  of  infiltration  is 
limited,  and  not  making  rapid  headway,  a  general  deriva- 
tive treatment  or  depletory  measures  may  be  of  service.  A 
hot  mustard  foot-bath,  followed  by  free  diaphoresis,  avoid- 
ing at  the  same  time  all  drinks,  may  prove  very  beneficial 
by  drawing  the  blood  to  the  periphery  and  diminishing  the 
local  pressure.  Tincture  of  belladonna,  five  drops  every  hour 
until  its  physiological  effect  becomes  marked,  by  contracting 
the  laryngeal  blood-vessels  is  also  valuable,  in  counteracting 


ACUTE  LARYNGITIS.  oJJ 

the  infiltration.  Local  applications  in  the  form  of  powders 
or  solutions,  with  brush  or  cotton  pledget,  should  be  strictly 
avoided,  their  mechanical  irritation  doing  more  harm  than 
the  agent  applied  does  good.  Steam  may  be  inhaled  with 
benefit,  and  the  atmosphere  of  the  room  of  the  patient  should 
be  rendered  moist  by  either  boiling  water  or  slacking  lime 
in  it.  The  steam  atomizer  shown  in  Fig.  79  may  be  used 
with  advantage  for  the  inhalations.  Although  I  have  had 
no  opportunity  of  treating  a  case  since  the  discovery  of 
cocaine,  it  seems  to  me  that  a  twenty  per  cent,  solution  of 
this  drug,  applied  with  a  fine  spray  atomizer,  would  produce 
a  marked  effect  in  depleting  the  infiltrated  parts.  Sprays  of 
alum  or  sulphate  of  zinc  (two  to  five  grains  to  the  ounce), 
are  recommended  by  Cohen.  Leeches  may  be  used  advan- 
tageously, five  or  six  being  applied  externally  some  distance 
from  the  thyroid  prominence. 

When  the  oadema  is  marked,  or  when  the  dyspnoea  is  evi- 
dent and  on  the  increase,  surgical  measures  should  be  re- 
sorted to.  The  swelling  must  be  scarified  and  relieved  of 
some  of  its  contents.  With  the  assistance  of  the  laryngeal 
mirror  the  procedure  is  very  easy.  The  ordinary  pocket-case 
curved  bistoury  may  serve  efficiently  for  the  purpose,  its 
blade,  as  far  as  to  within  a  line  of  the  point,  being  surrounded 
by  string,  to  prevent  cutting  of  the  parts  anterior  to  the 
larynx.  The  tongue  being  drawn  out,  the  epiglottis  will 
generally  be  seen  standing  erect  and  swollen.  This,  however, 
had  better  not  be  punctured,  lest  the  patient  object  to  further 
cutting.  The  mirror  being  introduced,  the  knife  is  passed 
around  the  side  of  the  epiglottis  and  its  point  is  caused  to 
penetrate  the  external  border  of  the  ary-epiglottic  fold,  thus 
causing  the  blood  and  serum  to  flow  into  the  pyriform  sinus, 
instead  of  the  laryngeal  cavity.  If  possible,  the  other  side 
had  better  be  treated  in  the  same  way.  Laryugeal  lancets, 


334  DISEASES   OF  THE  LAEYNX. 

especially  adapted  for  oedema,  are  generally  recommended, 
Lut  Leing  very  seldom  used,  they  are  usually  not  at  hand 
when  wanted,  and  it  is  Lest  not  to  depend  on  them.  One 
scarification  is  usually  sufficient  to  deplete  the  parts  effect- 
ually, the  relief  Leing  immediate.  A  second  is  seldom  re- 
quired. In  some  cases  the  symptoms  are  so  urgent  that 
even  this  procedure  is  not  sufficiently  rapid  to  save  the 
case,  and  tracheotomy  has  to  Le  performed. 

Traumatic  laryngitis  is  sometimes  followed  Ly  one  or  more 
aLscesses  near  the  seat  of  injury,  in  which  the  cartilages  may 
Lecome  implicated.  The  pus  should  Le  evacuated  Ly  free 
scarification. 

Convalescence  after  an  attack  of  acute  laryngitis  is  gen- 
erally quite  slow.  The  voice  remains  hoarse  for  a  time 
and  Lecomes  easily  fatigued.  It  is  frequently  followed  Ly 
chronic  laryngitis,  which  predisposes  the  patient  to  renewed 
attacks  of  the  acute  variety. 

(EDEMA   OF   THE   LAEYNX. 
(Synonyms: — (Edema  Glottidis;    (Edematous  Laryngitis.) 

Etiology. — Besides  occurring  as  a  complication  of  acute 
laryngitis,  oedema  of  the  larynx  may  .present  itself  without 
previous  local  inflammatory  manifestations.  The  larynx  may 
Lecome  the  seat  of  dropsical  effusion  in  diseases  character- 
ized in  their  advanced  stages  Ly  dropsy,  such  as  Bright's 
disease,  cirrhosis  of  the  liver,  cardiac  affections  and  phthisis ; 
or  suddenly,  Ly  exposure  to  cold  when  the  system  is  in  a 
weakened  condition.  (Edema  may  also  Le  caused  Ly  the 
administration  of  the  preparations  of  iodine,  especially  w^hen 
the  affection  for  which  such  a  preparation  is  given  is 
located  in  the  throat.  I  have  seen  two  such  cases,  in  one 
of  which  the  use  of  iodide  of  potassium  had  to  Le  stopped 


(EDEMA   OF   THE   LARYNX.  335 

definitively,  after  three  trials,  each  causing  marked  dyspnoea, 
which  ceased  as  soon  as  the  administration  of  the  drug  was 
discontinued. 

(Edema  of  the  larynx  may  become  chronic,  occurring  in 
that  case  as  a  concomitant  symptom  of  syphilitic  or  tuber- 
culous laryngitis  and  cancer.  The  acute  form  may  assume 
chronicity,  with  a  tendency  to  exacerbation. 

Pathology. — The  laxity  with  which  the  laryngeal  mucous 
membrane  is  attached  to  the  underlying  tissues  furnishes  a 
ready  explanation  for  the  facility  with  which  it  becomes  in- 
filtrated and  distended.  In  diseases  in  which  obstruction  to 
the  blood  current  becomes  an  important  element,  the  laryn- 
geal submucous  tissue  offers  but  little  resistance  to  the 
serous  effusion  which  can  here  produce  almost  instantaneous 
distention,  a  result  not  produced  in  other  parts,  the  limbs, 
hands,  abdomen,  etc. 

Symptoms. — Occasionally,  oedema  of  the  larynx  is  so  rapidly 
fatal  that  symptoms  can  hardly  be  said  to  have  existed. 
"\Vhen  occurring  in  the  course  of  dropsical  affections,  no  other 
symptom  may  present  itself  other  than  dyspnoea.  In  most 
cases,  however,  local  symptoms  are  evident:  heat  and  pain, 
a  sense  of  constriction  around  the  throat,  dryness,  and  im- 
peded respiration,  principally  during  inspiration.  As  the 
disease  progresses,  the  symptoms  become  more  marked, 
dyspnoea  is  more  evident,  the  expiration  as  well  as  the 
inspiration  being  impeded.  These  symptoms  may  consti- 
tute an  exacerbation  which  gradually  declines,  or  the  case 
may  proceed  from  bad  to  worse  until  death  takes  place. 

The  appearance  of  the  laryngeal  membrane  differs  from 
that  described  under  the  last  heading,  only  in  color.  Instead 
of  being  fiery  red,  resembling  somewhat  the  surface  of  a 
ripe  tomato,  it  is  pale,  at  times  almost  yellow,  watery,  and 
translucent,  appearing  much  like  an  cedematous  prepuce. 


336  DISEASES   OF   THE   LAKYNX. 

Prognosis. — (Edema  occurring  as  a  secondary  manifesta- 
tion of  another  disease,  is  more  likely  to  recur  than  that 
due  to  a  local  inflammatory  process,  unless  the  original 
cause  can  be  eradicated. 

Treatment, — Local  applications,  derivatives,  and  even  de- 
pletory measures  are  of  doubtful  value  in  this  variety  of 
oedema.  The  distended  folds  of  membrane  must  be  scarified 
freely  and  the  serum  evacuated.  The  manipulation  described 
under  the  last  heading  may  be  resorted  to,  or  the  finger  may 
be  introduced  into  the  mouth  and  used  as  guide  for  any 
pointed  instrument  that  may  be  at  hand.  The  incisions 
must  be  free,  and,  as  already  said,  should  be  made  as  much 
as  possible  on  the  edge  of  the  ary-epiglottic  folds,  so  as  to 
cause  the  serous  discharge  to  flow  into  the  pharynx,  instead 
of  the  larynx,  thus  avoiding  asphyxiation  by  flowing  liquid. 
After  the  incision,  the  fold  shrinks  suddenly;  the  relief  is 
immediate,  and  in  the  majority  of  cases,  lasting.  If  the 
dyspnoea  is  not  relieved  by  the  scarifications,  subglottic 
oedema  is  likely  to  be  present  also,  and  tracheotomy  is  the 
only  resource. 

CHEONIC   LARYNGITIS. 

(Synonyms  : — Chronic    Catarrhal    Laryngitis ;    Chronic    Laryngeal 

Catarrh.) 

Etiology. — Chronic  inflammation  of  the  vocal  bands  may 
result  from  repeated  attacks  of  subacute  laryngitis  in  con- 
nection with  acute  pharyngitis,  but  in  the  majority  of  cases 
it  assumes  the  chronic  form  from  the  first,  unpreceded  by 
acute  symptoms.  As  pointed  out  under  the  heading  of  hyper- 
trophic  rhinitis,  it  is  a  frequent  complication  of  this  affec- 
tion, the  chronic  catarrhal  inflammation  extending  by  con- 
tinuity of  tissue  to  the  larynx,  which  is  itself  made  subject 
to  all  the  exacerbations  which  the  nasal  disease  undergoes. 


CHEONIC   LAKYNGITIS.  337 

A  more  frequent  connection  between  the  two  diseases,  how- 
ever, is  the  irritation  kept  up  by  the  post-nasal  discharges, 
which  either  drop  into  the  larynx,  or  trickle  down  along  the 
posterior  pharyngeal  wall  until  the  inter-arytenoid  commis- 
ture  is  reached ;  here  they  accumulate  to  a  degree,  and  main- 
tain the  posterior  portion  of  the  larynx  in  a  constant  state 
of  irritation,  which  is  further  aggravated  by  the  coughing 
and  hacking  induced.  This  cause  of  chronic  laryngitis  is 
insisted  upon  by  Bosworth,  and  I  can  well  confirm  his 
opinion.  A  fact  which  I  have  frequently  noticed  in  this 
connection,  is  that  the  amount  of  chronic  laryngeal  inflam- 
mation is  in  proportion  to  the  degree  of  purulence  of  the 
discharges;  purely  mucoid  secretions  are  tolerated  by  the 
laryngeal  membrane  without  harm,  but  as  soon  as  they 
become  muco-purulent  or  purulent,  local  congestion  is  en- 
gendered, followed  frequently  by  erosions.  These  cause 
hoarseness,  cough,  and  expectoration  (the  sputa  being  formed 
principally  by  the  nasal  discharges),  and  the  presence  of 
phthisis  is  suspected.  When  hypertrophic  rhinitis  is  pres- 
ent and  sufficiently  marked  to  prevent  free  respiration 
through  the  nose,  oral  breathing  is  another  aggravating 
feature,  the  air  reaching  the  larynx  without  being  warmed, 
moistened  or  purified  of  its  extraneous  substances. 

Gastric  disturbances,  especially  those  caused  by  debaucherj", 
are  frequent  causes  of  chronic  laryngitis,  as  evidenced  by 
the  hoarseness  of  drunkards.  Hepatic  torpidity  is  another 
cause,  well  known  to  singers,  who  find  great  difficulty  in 
producing  clear  tones  when  "  bilious."  Excessive  use  of  the 
voice,  either  in  screaming  or  singing,  when  continued  for 
a  certain  period,  finally  causes  the  temporary  congestion, 
which  exists  at  the  time,  to  assume  the  chronic  state.  In 
hucksters,  for  instance,  hoarseness  is  almost  universal.  In 
singers,  a  prolonged  use  of  the  voice,  even  frequently  re- 

22 


338  DISEASES   OF   THE   LARYNX. 

peated,  is  tolerated  without  harm  under  certain  conditions, 
i.e.,  when  the  singer  has  received  judicious  training  and 
uses  his  voice  within  its  normal  compass ;  but  if  he  has  not, 
his  efforts  to  produce  as  high  a  note  as  possible  and  give  his 
voice  a  volume  which  it  does  not  possess,  strain  the  muscles, 
and  produce  in  them  an  inflammatory  state  which  soon  be- 
comes chronic  and  extremely  difficult  to  eradicate. 

The  continued  inhalation  of  air  containing  much  dust  or 
other  irritating  substances,  which  accompanies  many  occu- 
pations, is  another  frequent  cause ;  marble  cutters,  street 
sweepers,  and  colliers  being  probably  the  most  affected. 

Pathology. — The  epithelial  layer  of  the  vocal  bands  is 
generally  thickened  and  the  superficial  vascular  supply  in- 
creased. The  hypertrophic  process  may  involve  the  entire 
mucous  membrane,  but  in  the  majority  of  cases,  it  is  located 
in  the  posterior  portion  of  the  cavity,  gradually  extending 
to  the  other  parts.  The  muscles  are  frequently  the  principal 
location  of  the  inflammatory  process,  undergoing  in  some 
cases,  hyperplastic  induration.  The  principal  cause  of  the 
hoarseness,  however,  lies  in  the  thickened  condition  of  the 
vocal  bands,  or  rather  of  the  membrane  covering  them; 
their  vibration  is  devoid  of  the  regularity  and  freedom 
necessary  for  the  production  of  a  pure  tone,  and  the  note 
is  cracked  or  irregular.  When  the  muscular  tissues  are 
involved,  the  pitch  can  only  be  altered  with  great  difficulty, 
the  extension  and  relaxation  of  the  bands  being  interfered 
with  according  to  the  degree  of  inflammation.  Implication 
of  the  arytenoideus  is  a  frequent  cause  of  aphonia,  which 
sometimes  occurs  in  the  course  of  the  affection. 

Symptoms. — The  symptoms  of  chronic  laryngitis  consist 
principally  in  an  alteration  of  the  purity  of  the  voice.  The 
hoarseness  is  not  always  continuous,  however,  but  generally 
occurs  after  the  voice  has  been  used  a  short  time.  In  some 


CHRONIC  LARYNGITIS.  339 

cases,  the  contrary  is  the  case ;  the  voice,  at  first,  is  quite 
hoarse,  but  after  a  few  words  or  phrases,  it  becomes  clearer 
and  clearer,  until  it  has  returned  to  its  normal  condition. 
This  does  not  last  long,  however;  the  voice,  soon  becomes 
tired  and  resumes  its  hoarseness.  Its  pitch  is  usually 
lowered. 

Cough,  provoked  by  a  tickling,  itching  sensation  in  the 
throat,  is  present  in  the  majority  of  cases,  and  is  accom- 
panied by  more  or  less  expectoration,  according  to  the  cause 
of  the  trouble.  There  is  seldom  pain,  a  feeling  of  heat  and 
constriction  being  more  frequently  complained  of.  Complete 
loss  of  voice  is  not  a  rare  occurrence,  but  it  generally  returns 
after  a  few  days'  rest. 

Left  to  itself,  the  disease,  in  some  cases,  becomes  aggra- 
vated. General  symptoms,  such  as  fever,  pyrexia,  emacia- 
tion, gastric  and  intestinal  disorders,  supervene.  Locally, 
the  abrasions  become  active  ulcerations,  and  a  purulent, 
fetid  expectoration,  often  streaked  with  blood,  violent  and 
harassing  cough,  pain  extending  to  the  ears,  and  dysphagia, 
render  confusion  of  the  disease  with  the  local  manifestations 
of  tuberculous  or  syphilitic  laryngitis  quite  possible.  Chon- 
dritis  or  perichondritis  may  occur  and  bring  on  a  fatal 
termination. 

Viewed  with  the  laryngoscope,  the  larynx  presents  a  con- 
gested appearance,  marked  in  proportion  to  the  degree  of 
active  inflammation.  The  epiglottis  is  also  congested,  en- 
larged vessels  coursing  over  its  posterior  surface.  The  out- 
line of  the  prominences  of  Wrisberg  and  Santorini  is  some- 
what obscured,  and  they  present  the  same  color  as  the 
surrounding  parts.  The  general  redness  is  not  so  great  as 
in  acute  or  even  as  in  a  marked  case  of  subacute  laryngitis, 
but  the  thickened  appearance  of  the  membrane  and  its 
irregular  surface  presents  quite  a  marked  contrast  with  the 


o4:0  DISEASES   OF   THE   LARYNX. 

former.  The  vocal  bands  are  more  or  less  congested,  ac- 
cording to  the  stage  of  the  disease ;  they  may  present  only  a 
slight  pinkish  appearance  or  be  as  red  as  raw  beef,  cream- 
like,  stringy  mucus  adhering  to  them,  and  forming  films 
when  they  are  separated.  In  phonation  the  bands  appeal- 
relaxed  ;  their  edges,  which  are  thickened,  do  not  appear  to 
come  accurately  together,  and  an  elliptical  opening  is  occa- 
sionally observed  between  them.  This  want  of  parallelism 
is  due  to  paresis  of  the  laxors  of  the  vocal  bands,  through 
inflammatory  infiltration. 

Prognosis. — In  the  majority  of  cases  of  chronic  laryngitis, 
when  local  ulceration  and  chondritis  are  not  present,  the 
prognosis  is  quite  favorable.  When  the  case  is  of  long  dura- 
tion and  the  muscles  have  become  markedly  infiltrated  by 
inflammatory  products,  which  have  to  a  certain  degree  become 
organized,  hoarseness  is  likely  to  remain  after  all  the  other 
symptoms  have  disappeared. 

Treatment. — The  maintenance  of  local  cleanliness  is  of  the 
greatest  importance  in  this  affection,  and  superficial  erosions 
and  ulcerations  will  often  disappear  under  the  frequent  ap- 
plication of  a  detergent  spray  of  borax  (gr.  iv-lj)  to  which 
a  few  drops  of  cologne  have  been  added.  In  the  fetid  variety, 
permanganate  of  potash  (gr.  j-Ij)  may  be  used,  its  stimulating 
properties  tending  to  limit  the  ulcerative  process.  For  office 
use,  Sass'  laryngeal  spray  tube  is  probably  the  best  instru- 
ment, its  dense  spray  offering  slight  and  gentle  mechanical 
force  for  the  removal  of  the  secretions.  For  the  patient's 
use,  the  laryngeal  atomizer,  shown  in  Fig.  78,  is  a  conve- 
nient instrument.  Its  spray  is  continuous  and  sufficiently 
large  to  bathe  the  parts  thoroughly. 

The  frequency  with  which  the  parts  should  be  cleansed 
depends  entirely  upon  the  amount  of  secretion ;  twice  a  day 
is  usually  sufficient,  however,  the  patient  being  directed  to 


CHRONIC  LARYNGITIS.  o4 

inhale  through  the  mouth  while  using  the  instrument.  In 
order  to  render  a  cure  possible,  all  general  conditions  or  dis- 
eases bearing  influence  upon  the  etiology  of  chronic  laryn- 
gitis, must  be  eradicated.  All  affections  of  the  nose  or 
pharynx  should  be  appropriately  treated.  The  bowels  fre- 
quently need  attention  and  I  have  seen  cases  much  benefited 
by  simple  measures  directed  to  them.  Friedrichshall  water 
is  probably  the  best  alkaline  water  at  our  disposal,  its  salines 
producing,  besides  the  derivative  action,  beneficial  local 
action.  Gastric  and  hepatic  disturbances  should  be  met  with 
appropriate  remedies,  while  any  underlying  diathesis  that 
may  be  present  should  also  receive  attention.  Due  care,  as 
regards  general  hygienic  measures,  diet,  etc.,  should  also  be 
exercised. 

Local  applications,  after  cleansing,  are  best  made  with  the 
atomizer,  the  cotton  pledget  being  only  used  to  touch  spots 
of  ulceration  with  the  stronger  agents.  For  the  general  con- 
gestion I  have  not  found  strong  solutions  produce  a  benefi- 
cial effect,  weaker  ones  giving  rise  to  less  irritation.  Before 
resorting  to  these,  however,  the  spots  of  ulceration  should 
first  receive  attention.  A  sixty-grain  solution  of  nitrate  of 
silver,  as  advocated  by  Setter,  has  been  most  serviceable  in 
my  hands,  and  a  few  applications  generally  suffice  to  cause 
their  disappearance.  Of  late,  I  have  partially  anaesthetized 
the  larynx  with  a  ten  per  cent,  solution  of  cocaine  to  make 
these  applications,  and  have  been  able  to  locate  them  with 
greater  accuracy.  A  small  piece  of  cotton  only  should  be 
used,  which,  having  been  adjusted  to  the  end  of  the  forceps 
and  dipped  in  the  solution,  should  be  lightly  squeezed  be- 
tween the  folds  of  a  towel  to  prevent  dripping.  With  these 
precautions,  no  danger  of  spasm  need  be  feared.  A  strong 
solution  of  sulphate  of  copper  (gr.  xxx-3j)  is  also  very 
efficient  in  those  cases,  but  not  so  much  so  as  nitrate  of 


342  DISEASES   OF   THE   LARYNX. 

silver.  Chloride  of  zinc  (gr.  x-3j)  is  effective  when  the  ulcer- 
atious  give  rise  to  much  discharge,  accompanied  with  fetor. 
Any  of  these  applications  should  be  made  about  twice  a 
week. 

For  the  treatment  of  the  general  surface  of  the  larynx,  I 
have  noticed  that  a  two  per  cent,  solution  of  cocaine,  used 
two  or  three  minutes  three  times  a  day,  produced  great  relief ; 
after  its  application  the  membrane  presents  a  paler  appear- 
ance, the  effect  of  the  drug  upon  the  blood-vessels  being  to 
contract  them.  Mild  solutions  of  alum  (gr.  iij-lj),  applied  in 
the  same  manner,  are  also  beneficial.  An  excellent  remedy 
in  some  cases  is  the  0  cosmoline,  applied  in  the  form  of 
spray  with  the  atomizer  shown  in  Fig.  78.  It  covers  the 
membrane  with  a  thin  film,  which  protects  it  effectually  for 
a  time.  Applied  immediately  after  the  astringents,  it  seems 
to  enhance  their  action. 


CHAPTER  XXVI. 

DISEASES   OP  THE  LARYNX. — (Continued.) 
TUBERCULOUS  LARYNGITIS. 

(Synonyms : — Consumption  of  the  Throat ;   Laryngeal  Phthisis.) 

Etiology. — The  opinion  still  entertained  by  the  majority  of 
observers,  is  that  tuberculous  laryngitis  is  a  secondary  mani- 
festation of  tuberculosis  of  the  lungs.  That  it  may  be  pri- 
mary is  still  a  mooted  question,  owing  to  the  impossibility 
of  always  ascertaining  the  presence  or  absence  of  lung  dis- 
ease when  the  laryugeal  affection  declares  itself.  The  fact, 
however,  that  in  a  small  number  of  cases  reported  the  laryn- 
geal  affection  had  reached  an  advanced  stage  before  the 
presence  of  the  pulmonary  trouble  could  be  detected,  seems 
to  indicate  a  likelihood  that  tuberculous  laryngitis  can  occur 
primarily.  Males  are  more  predisposed  to  it  than  females, 
owing  probably  to  the  greater  degree  of  exposure  to  which 
the  former  are  subjected,  while  age  seems  also  to  bear  great 
influence  as  a  predisposing  cause,  the  fifteen  years  between 
the  ages  of  twenty  and  thirty-five  presenting  a  much  greater 
proportion  of  cases  than  other  periods  of  life. 

Pathology. — The  tubercular  deposits  or  miliary  tubercles  in 
the  membrane,  are  described  as  small  spherical  elevations, 
which  appear  in  greater  or  less  numbers  through  its  surface ; 
in  the  epiglottis,  they  are  principally  lodged  beneath  the 
membrane  in  the  depressions  or  cavities  of  the  cartilage.  In 
a  small  proportion  of  cases  of  pulmonary  tuberculosis,  the 
laryngeal  tubercles  undergo  the  same  pathological  process 
as  those  in  the  lungs,  and  if,  as  is  almost  always  the  case, 

*  (343) 


344  DISEASES   OF   THE   LARYNX. 

one  lung  only  is  involved,  the  first  manifestations  in  the 
larynx  will  generally  appear  on  the  same  side.  As  the 
ulcerative  process  continues,  tissues  and  cartilages  may 
gradually  become  involved  and  destroyed. 

Symptoms. — The  early  symptoms  of  the  affection  are  so  in- 
sidious as  hardly  to  be  perceived.  After  a  time,  slight  hoarse- 
ness is  noticed,  which  is  usually  ascribed  to  the  co-existing 
pulmonary  trouble;  a  feeling  of  heat  and  dryness  is  expe- 
rienced in  the  throat,  accompanied  by  pain  of  a  lancinating 
character,  shooting  occasionally  to  the  ears.  Deglutition 
becomes  painful  if  the  ulcerations  involve  the  border  of 
the  epiglottis  and  the  ary-epiglottic  folds,  but  as  a  general 
thing,  dysphagia  only  occurs  later  on.  As  the  disease  pro- 
gresses, the  hoarseness  increases,  and  frequently  the  patient 
becomes  completely  aphonic.  The  pulse,  temperature,  and 
other  general  symptoms  are  those  of  pulmonary  phthisis,  but 
emaciation  takes  place  more  rapidly  than  in  the  latter  affec- 
tion, the  odynphagia  causing  the  patient  to  abstain  from 
food  as  much  as  possible.  When  the  disease  has  reached 
an  advanced  stage,  dyspnoea  supervenes,  and  that,  added  to 
the  already  difficult  respiration  occurring  as  a  result  of  the 
pulmonary  affection,  causes  the  patient  to  suffer  greatly. 
Tracheotomy  is  sometimes  required.  The  cough  incident 
upon  the  lung  trouble,  which  under  ordinary  circumstances 
is  not  painful,  becomes  excruciatingly  so  in  this  affection, 
the  pain  continuing  a  good  while.  The  sufferings  of  the 
patient  continue  to  increase  until  death  comes  to  his  relief. 

Upon  examination  in  the  early  stage,  the  membrane 
of  the  larynx  and  the  surrounding  parts  generally  appears 
pale,  a  yellow  tint  pervading  what  pink  may  have  remained. 
In  some  cases  this  pallor  is  so  marked  that  the  parts  look 
perfectly  blanched.  A  charr.cteristic  symptom  occurring  in 
the  majority  of  the  cases  in  which  the  affection  first  shows 


TUBERCULOUS  LARYNGITIS.  343 

itself  ill  the  larynx  proper,  are  pyrifovm  swellings  of  either 
of  the  arytenoid  prominences  or  sometimes  both,  looking  like 
rounded  cushions,  which  enlarge  at  the  'expense  of  the  laryn- 
geal  aperture.  They  generally  present  the  pale  hue  of  the 
surrounding  parts,  but  may  appear  quite  red  and  occasionally 
livid.  The  mechanical  impediment  which  they  offer  to  the 
closure  of  the  epiglottis,  renders  deglutition  difficult,  and 
liquids  are  prone  to  cause  considerable  annoyance  by  running 
into  the  larynx  and  causing  violent  coughing  and  gagging. 
The  vocal  bands  may  appear  hardly  influenced  by  the 
disease  for  a  considerable  time  after  the  early  manifestations, 
but  they  generally  show  evidences  of  involvement  very  soon 
after,  or  simultaneously  with  them.  They  may  appear  highly 
inflamed  and  fiery,  but  they  frequently  do  not  present  even 
the  slightest  redness,  and  spots  of  ulceration,  forming  inden- 
tations upon  their  thickened  edges,  may  occur  in  such 
number,  as  to  cause  a  dentated  appearance,  the  free  borders 
of  the  bands  resembling  the  edge  of  a  curry-comb.  The 
voice,  in  these  cases,  becomes  impaired  almost  with  the  out- 
break of  the  local  trouble,  and  is  soon  lost.  Active  inflam- 
mation, involving  the  entire  larynx,  is  generally  present,  how- 
ever, and  small  spots  of  ulceration,  at  first  appearing  like 
mere  abrasions,  with  a  grayish  surface,  may  be  met  with  in 
any  part  of  the  cavity,  but  most  frequently  over  the  aryte- 
noid commissure,  where  they  are  usually  covered  by  the 
secretions  emanating  from  the  diseased  lung.  These  ulcera- 
tions  gradually  deepen  and  spread,  the  inflammation  in- 
creasing at  the  same  time.  The  general  shape  of  the  larynx 
may  become  completely  altered,  and  the  vocal  bands,  or  what 
may  be  left  of  them,  become  hardly  discernible  amongst 
irregularly  distributed  swellings  and  ulcerated  surfaces.  In 
a  small  proportion  of  the  cases,  the  ulcerative  process  begins 
in  the  membrane  of  the  epiglottis,  and  rapidly  spreads  to 


H46  DISEASES   OF   THE   LARYNX. 

the  surrounding  parts,  involving  sometimes  the  base  of  the 
tongue  and  the  palatine  folds.  The  epiglottis  in  these  cases 
becomes  infiltrated  and  swollen,  and  assumes  the  shape  which 
causes  it  to  be  termed  "turban"  epiglottis,  owing  to  its  re- 
semblance to  a  Turk's  turban.  In  many  instances,  the  first 
local  evidence  of  the  affection  is  a  grayish  prominence  in  the 
laryngeal  aspect  of  the  arytenoid  commissure,  often  mis- 
taken for  a  papilloma.  It  may  be  rounded  or  resemble 
pointed  crests.  I  have  seen  it  present  a  fimbriated  appear- 
ance and  involve  the  entire  laryngeal  surface  of  the  ary- 
tenoid commissure.  These  papillary  excrescences  are  not 
limited  to  this  locality,  however,  but  may  be  developed  in 
any  portion  of  the  mucous  membrane. 

Prognosis. — Although  a  number  of  recoveries  have  been 
reported,  even  in  cases  in  which  the  affection  had  advanced 
considerably,  we  can  hardly  hope  to  do  much  more  than 
retard  its  progress,  and  thereby  prolong  for  a  few  months 
the  life  of  the  patient.  When  the  epiglottis  is  the  first  part 
of  the  larynx  involved,  the  fatal  issue  is  likely  to  occur  at 
an  early  date. 

Treatment. — Although  the  number  of  well  authenticated 
successful  results  reported  is  riot  large,  the  possibility  of 
recovery  under  appropriate  treatment  is  sufficiently  demon- 
strated to  place  the  practitioner  under  the  stress  of  consider- 
able responsibility.  In  this  affection,  more  perhaps  than  in 
any  other,  the  life  of  the  patient  is,  to  a  certain  degree,  in 
his  hands ;  by  his  assiduous  care  he  can  certainly  prolong 
it  for  a  short  time  at  least,  and  perhaps  cure  the  disease. 
To  Dr.  F.  H.  Bosworth,  of  New  York,  the  profession  is  in- 
debted for  the  practical  demonstration  of  this  fact,  and, 
although  I  can  only  add  one  successful  case  to  several  re- 
ported by  him,  it  certainly  serves  to  show  the  value  of  his 
suggestions,  and  to  encourage  renewed  efforts  in  subsequent 


TUBEKCULOUS  LARYNGITIS.  347 

opportunities.  The  general  outline  of  the  treatment  followed 
by  him  is  as  follows :  (1)  the  thorough  cleansing  of  the  parts 
preparatory  to  the  more  special  application ;  (2)  the  appli- 
cation of  such  mild  astringents,  alteratives,  or  resolvents  as 
may  be  indicated;  (3)  the  application  of  an  anodyne  to  re- 
lieve pain  or  irritability,  and  to  correct  irritation  caused 
by  the  previous  remedies ;  (4)  the  application  of  iodof orm  as 
a  specific  in  its  action  on  ulcerations  of  mucous  membranes. 
For  cleansing  purposes,  Sass'  spray  tube,  used  gently, 
is  the  most  satisfactory  instrument,  the  adhesive  nature  of 
the  sputa  requiring  some  slight  mechanical  force  for  its 
removal.  I  have  generally  found  a  solution  of  borax  (gr.  iv- 
Ij)  most  agreeable  to  the  patient  as  a  detergent  spray,  its 
disinfecting  qualities  being  an  important  feature.  The  larynx 
being  thoroughly  cleansed,  the  anodyne  is  next  in  order; 
cocaine  in  this  connection  is  of  the  greatest  value,  and  a  two 
per  cent,  solution,  used  with  an  atomizer  throwing  a  fine 
spray,  is  not  only  exceedingly  soothing,  but  it  facilitates 
greatly  the  subsequent  steps.  If  cocaine  cannot  be  obtained, 
a  five  or  ten  grain  solution  of  morphia,  as  recommended  by 
Bosworth,  may  be  used,  a  little  bicarbonate  of  sodium  being 
added  to  give  it  an  alkaline  reaction.  The  application  of  an 
astringent  comes  next;  this  should  also  be  used  with  the 
atomizer,  to  avoid  as  much  as  possible  the  contact  of  instru- 
ments. I  have  found  nitrate  of  silver  (gr.  ij-ij)  more  satis- 
factory than  tannin  (gr.  x-3j),  or  sulphate  of  zinc  (gr.  v-lj), 
producing  less  irritation.  In  some  cases,  however,  the  latter 
will  perhaps  be  better  borne.  In  using  iodoform,  I  prefer 
the  method  proposed  by  the  late  Dr.  Elsberg,  ?'.e.,  dissolving 
the  drug  in  ether.  I  use  a  saturated  solution,  which  is  also 
applied  by  means  of  the  atomizer.  Powders  cause  an  un- 
comfortable sensation  of  dryness,  which  lasts  sometimes  a 
couple  of  hours,  while  the  cotton  pledget,  the  brush  or  the 


3-48  DISEASES   OF   THE   LARYNX. 

sponge  render  mechanical  irritation  unavoidable.  The  atom- 
izer reaching  the  desired  spot  as  well,  it  should  receive  the 
preference.  This  treatment,  which  should  be  repeated  at 
least  every  other  day,  is  generally  tedious  to  both  patient 
and  physician,  but  the  relief  furnished  certainly  repays  the 
trouble.  For  the  patient's  use,  I  have  of  late  prescribed  the 
two  per  cent,  solution  of  cocaine,  to  be  used  with  the  atom- 
izer, just  before  eating,  and  sufficiently  between  meals  to 
subdue  pain.  The  effect  produced  is  so  satisfactory,  that 
the  patients  are  generally  anxious  to  use  the  solution  more 


Bryson  Delavan's  alimentation  bottle. 

frequently  than  directed  to.  Another  convenient  way  to 
administer  the  cocaine,  is  to  have  it  put  up  in  the  form  of 
lozenges,  gr.  i  to  the  lozenge,  one  being  used  as  often  as  re- 
quired. Deglutition  being  facilitated,  the  sufferer  is  better 
nourished,  while  the  diminished  suffering  is  a  source  of  great 
satisfaction.  "When  deglutition  becomes  impossible  through 
extensive  ulceration,  Bryson  Delavan's  alimentation  bottle, 
shown  in  Fig.  81,  may  be  employed  to  great  advantage.  A 
flexibe  catheter  of  small  size,  replaces  the  ordinary  stomach 
tube,  and  is  introduced  not  into  the  stomach,  but  simply 


SYPHILITIC   LARYNGITIS.  349 

below  the  pharyngeal  constrictors,  or  beyond  the  seat  of  the 
difficulty.  Cough  is  also  greatly  decreased.  The  general 
treatment  is  that  indicated  for  the  co-existing  pulmonary 
trouble,  tonics  and  stimulants  forming  the  principal  feature. 
Should  the  dyspnoea  become  alarming,  tracheotomy  may 
become  necessary.  When  it  is  performed,  a  temporary  favor- 
able reaction  seems  to  take  place,  but  unfortunately  it  is 
only  of  short  duration. 

SYPHILITIC  LAKYNGITIS. 
(Synonyms  : — Syphilis    of  the    Larynx ;     Specific    Laryngitis.) 

Etiology. — Syphilitic  laryngitis  most  frequently  occurs  as 
a  manifestation  of  the  tertiary  period,  from  three  to  thirty 
years  after  the  primary  infection.  As  a  complication  of  the 
secondary  stage  of  syphilis,  it  may  present  itself  from  a  few 
weeks  to  one  year  after.  Primary  syphilis  of  the  larynx  is 
extremely  rare.  Syphilitic  laryngitis  is  more  frequent  in 
inen  than  in  women,  this  being  explained  by  the  fact  that 
the  former  being  more  exposed,  the  throat  is  more  fre- 
quently congested,  and  becomes  an  easier  prey  to  the  ravages 
of  the  affection.  The  influence  of  climate  is  shown  by  the 
greater  frequency  of  the  disease  during  winter  than  at  other 
times  of  the  year.  It  may  also  be  due  to  heredity. 

Pathology. — The  pathological  manifestations  of  syphilis  in 
the  larynx  are  extremely  varied,  and  comprise  the  great 
majority  of  lesions  that  the  disease  can  present.  In 
secondary  syphilis,  the  local  lesion  may  consist  of  mere 
hypersemia  of  short  or  prolonged  duration,  giving  rise  to 
the  symptoms  of  simple  laryngitis;  this  hyperjpmia  may  be 
complicated  with  more  or  less  deep  ulcerations  which  heal 
spontaneously,  or  with  condylomata,  which  may  undergo 
ulceration  or  disappear  of  their  own  accord.  In  tertiary 


350  DISEASES   OF   THE   LARYNX. 

syphilis,  hypercemia  is  also  the  first  manifestation,  followed 
by  ulceration,  either  starting  on  the  surface  or  beneath  the 
membrane,  and  progressing  rapidly.  It  occasionally  extends 
to  the  cartilages,  and  is  liable  to  cause  stenosis  by  the  cica- 
tricial  contraction  which  follows  resolution,  wrhen  this  takes 
place.  Gummata  are  also  of  occasional  occurrence, 

Symptoms. — In  secondary  syphilis  of  the  larynx,  the  symp- 
toms are  usually  confined  to  those  manifested  in  the  course 
of  an  attack  of  simple  acute  pharyngitis,  superficial  ulcera- 
tion of  the  mucous  membrane  or  mucous  patches,  if  they 
occur,  increasing  the  local  soreness  and  the  inflammation. 
The  voice  is  generally  affected  early,  a  peculiar,  low-pitched 
hoarseness  accompanying  ordinary  speech  when  the  vocal 
bands  are  implicated.  Pain  in  the  surrounding  parts  and 
odynphagia  are  more  or  less  prominent  symptoms,  according 
to  the  location  of  the  laryngeal  cavity  presenting  the  ulcera- 
tion. A  short,  hacking  cough,  with  more  or  less  expectora- 
tion of  stringy  mucus  or  muco-pus,  is  usually  present.  The 
suffering,  in  any  of  its  features,  is  not  to  be  compared  with 
that  of  tuberculous  laryngitis. 

Examined  laryngoscopically,  the  appearance  of  the  larynx 
at  first  resembles  so  much  that  of  subacute  laryngitis  that  a 
differential  diagnosis  can  only  be  established  with  great  diffi- 
culty. Even  if  a  clear  history  of  syphilitic  infection  can  be 
obtained,  the  true  etiology  of  the  manifestation  can  only  be 
suspected,  since  the  laryngeal  inflammation  can  also  be  due 
to  the  ordinary  causes  of  subacute  laryngitis,  without  at 
all  involving  the  general  specific  intoxication.  A  feature 
which  assists  greatly  in  the  differentiation  of  the  two  affec- 
tions when  it  is  sufficiently  marked,  is  the  irregularity  of  the 
congestion  in  syphilitic  laryngitis;  it  occurs  more  in  spots, 
which  seem  to  bulge  out  from  the  surface.  These  elevations 
may  be  numerous  on  one  side  of  the  larynx,  while  on  the 


SYPHILITIC   LARYNGITIS/  351 

other  they  may  be  quite  scarce,  the  vocal  bands  on  the  most 
affected  side  presenting  more  congestion  than  that  on  the 
other.  This  irregular  appearance  is  by  no  means  seen  in 
every  case,  and,  in  the  majority,  further  developments  are 
necessary  to  establish  a  positive  diagnosis.  When  mucous 
patches  appear,  their  concurrence  with  patches  under  the 
tongue  or  other  parts  of  the  oral  cavity,  serves  to  differ- 
entiate the  condition  from  any  other.  They  most  frequently 
appear  upon  the  ventricular  bands,  the  inter-arytenoid  space 
and  the  epiglottis ;  they  present  the  same  appearance  as  in 
other  localities — a  regular  outline  with  a  slight  inflamma- 
tory areola  around  them,  and  a  whitish  surface  covered  with 
a  yellowish  secretion.  As  a  rule,  and  especially  under  appro- 
priate treatment,  they  disappear  after  a  week  or  two,  leaving 
a  reddish  spot  Avhich  gradually  vanishes.  Occasionally,  they 
become  irregularly  covered  with  granulations,  which  some- 
times assume  sufficient  size  to  require  removal  by  surgical 
means.  Condylomata  are  occasionally  met  with ;  they  re- 
semble small,  yellow  pimples  on  an  elevated  base.  They 
generally  disappear  of  their  own  accord. 

Tertiary  ulcerations  usually  present  themselves  on  the  epi- 
glottis first,  its  edge  or  its  oral  surface  being  their  favorite 
site.  They  then  make  their  appearance  in  the  laryngeal 
cavity  and  the  trachea.  Here,  again,  a  certain  amount 
of  difficulty  presents  itself  in  the  differentiation,  but  in  this 
case,  tuberculous  ulceration  and  carcinoma  are  the  local 
lesions  with  which  it  is  likely  to  be  confounded.  In  tubercu- 
losis, however,  the  pulmonary  symptoms,  almost  always 
present,  assist  materially  in  the  differentiation,  while  the 
anaemic  appearance  of  the  pharynx  and  the  soft  palate, 
and  frequently  of  the  larynx  itself,  furnish  further  evidence ; 
to  these  may  be  added  greater  local  pain  and  dysphagia. 
In  carcinoma,  the  pain  is  of  a 'lancinating  character,  and 


JU2  DISEASES   OF   THE   LARYNX. 

usually  very  sharp,  while  in  syphilis  it  is  dull  and  continu- 
ous. The  cachectic  appearance  of  the  skin,  when  present  in 
cancerous  individuals,  is  also  of  some  assistance.  Tertiary 
ulcerations  differ  from  those  of  the  secondary  period  in  that 
they  are  deep  instead  of  superficial,  the  pathogenic  process 
beginning  in  the  deep  layers  of,  or  beneath  the  membrane, 
and  presenting  elevations  which  finally  break  down.  The 
ulcer  formed  is  thus  deep-seated  from  the  start;  it  extends 
rapidly,  both  in  breadth  and  in  depth,  seldom,  however,  in- 
volving the  surrounding  cavities  or  organs. 

A  peculiarity  of  syphilitic  ulcerations,  is  that  they  fre- 
quently occur  symmetrically  on  both  sides,  a  spot  of  ulcer- 
ation  occurring  on  the  ventricular  band  on  one  side,  for 
instance,  being  often  followed  by  another  on  the  other 
ventricular  band  Their  edges  are  ragged  and  sharp  cut, 
and  a  deep  red  or  purplish  areola  surrounds  them.  Their 
surface  is  covered  with  a  greenish-yellow  discharge,  which 
is  secreted  profusely  and  contains  shreds  of  necrosed  tissue. 
A  fetid  odor  is  usually  emitted,  which  renders  the  breath 
of  the  patient  offensive.  The  epiglottis  is  often  completely 
destroyed ;  when  the  ulceration  extends  to  the  other  car- 
tilages, these  become  partially  or  entirely  necrosed,  and 
are  expectorated  either  whole  or  in  pieces;  the  latter  may 
endanger  the  patient's  life  by  falling  into  the  glottis  and 
causing  asphyxia. 

Blood-vessels  may  become  implicated  in  the  ulcerative 
process  and  severe  hemorrhage  ensue.  The  ulcerative  pro- 
cess is  rapid  and  destructive,  and  if  the  disease  is  not 
arrested  until  the  ulcerations  have  made  much  headway, 
the  cicatricial  contraction  of  the  excavated  tissues  causes 
further  deformity  of  the  larynx,  and  bands  of  cicatricial 
tissue  so  limit  the  glottis  or  other  parts  of  the  laryngeal 
cavity  as  to  interfere  greatly  with  respiration,  and  some- 
times to  cause  complete  stenosis. 


SYPHILITIC   LARYNGITIS.  353 

The  subjective  symptoms  resemble,  at  the  start,  those  of  an 
attack  of  subacute  laryngitis.  Aggravation  soon  takes  place, 
however,  accompanied  by  local  heat  and  pain,  especially 
marked  during  deglutition;  the  expectoration  assumes  a 
purulent  character  and  is  quite  profuse,  being  at  times 
streaked  with  blood ;  the  voice  becomes  hoarse,  and  complete 
aphonia  follows,  if  the  ulcerative  process  involves  both  vocal 
bands  or  the  inter-arytenoid  commissure.  As  the  destruction 
of  tissue  and  cartilage  continues,  these  symptoms  increase 
in  virulence,  deglutition  becoming  almost  impossible. 

Prognosis. — Under  proper  treatment,  syphilitic  laryngitis, 
even  when  far  advanced  in  the  tertiary  period,  is  almost 
always  curable.  After  the  latter,  however,  considerable  de- 
formity generally  occurs,  compromising,  in  many  cases,  the 
physiological  functions  of  the  larynx,  and  endangering  the 
patient's  life. 

Treatment. — In  secondary  laryngeal  manifestations,  the  local 
treatment  principally  consists  in  frequent  detergent  sprays,  to 
keep  the  laryngeal  surface  as  free  as  possible  from  unhealthy 
secretions.  This  of  course  only  applies  to  cases  in  which 
there  is  ulceration.  A  borax  spray  (gr.  iv-3j)  applied  three 
or  four  times  daily,  not  only  contributes  materially  to  the 
patient's  comfort,  but  advances  the  recovery.  Astringents  are 
recommended  by  some  authors,  but  I  have  found  them  more 
irritating  than  beneficial.  If  the  superficial  ulceration  seems 
stubborn,  a  sixty-grain  solution  of  nitrate  of  silver,  applied 
with  a  very  small  cotton  pledget  to  each  spot,  after  partially 
anaesthetizing  the  larynx  with  cocaine,  will  soon  cause  them 
to  disappear. 

Although  the  tendency  of  secondary  syphilis  of  the  larynx 
is  to  undergo  spontaneous  resolution,  when  the  diagnosis  is 
rendered  positive  by  the  mucous  patches  and  the  other  evi- 
dences described,  a  mercurial  treatment  is  indicated,  not  for 

28 


354  DISEASES   OF   THE   LARYNX. 

the  secondary  manifestations,  but  to  prevent  as  much  as  pos- 
ble  the  tertiary  stage  of  the  affection.  The  red  iodide  of 
mercury,  administered  in  doses  of  one-sixteenth  of  a  grain 
three  times  daily,  may  be  prescribed,  and  alternated,  when 
ptyalism  occurs,  with  iodide  of  potassium,  ten  grains  night 
and  morning.  After  continuing  this  treatment  for  six 
weeks  or  two  months,  "Rabuteau's  pills  of  carbonate  of  iron 
are  of  advantage  if  ana3inia  is  present,  one  being  taken  after 
meals. 

In  tertiary  syphilis  of  the  larynx,  internal  medication  is  of 
primary  importance.  The  system  must,  as  soon  as  possible, 
be  placed  under  the  influence  of  an  anti-syphilitic  treatment, 
to  check,  in  the  briefest  time,  the  ulcerative  process.  Mer- 
curial inunctions,  practiced  three  times  a  day,  a  piece  of 
mercurial  ointment  as  large  as  a  cherry  being  rubbed  into 
a  different  part  of  the  body  each  time,  is  rapidly  effective. 
The  ulcerations  show  marked  improvement  after  a  few  days, 
after  which  the  inunctions  may  be  reduced  to  twice  a  day. 
When  ptyalism  becomes  evident,  the  mercury  is  replaced  by 
iodide  of  potassium,  which  should  in  turn  be  given  in  large 
doses,  beginning  with  ten  grains,  and  gradually  increasing 
at  the  rate  of  one  grain  per  day  until  twenty  grains  are  ad- 
ministered three  times  a  day.  While  the  drug  is  being  used, 
the  urine  must  be  watched,  and  if  it  becomes  scanty  or  its 
specific  gravity  becomes  abnormally  increased,  prudence  must 
be  exercised  lest  oedema  of  the  larynx  occur.  The  larynx 
should  be  frequently  and  carefully  examined,  and  if  it  shows 
unusual  puffiness  or  the  patient  complains  of  dyspnoea,  the 
iodide  must  either  be  decreased  or  discontinued  as  the  case 
may  be.  This  step  is  seldom  necessary,  however,  and  when 
the  maximum  dose  of  the  salt  has  been  administered,  it  can 
be  continued  as  required,  and  decreased  as  it  was  increased, 
one  grain  per  day.  To  prevent  gastric  disturbance,  the  iodide 


SYPHILITIC   LARYNGITIS.  355 

can  be  administered  with  tincture  of  cinchona  bark.  The 
salt  should  be  dissolved  in  a  little  water  by  the  pharmacist, 
prior  to  mixing  it  with  the  tincture,  to  insure  proper  solu- 
tion. 

Local  applications  are  also  very  important,  not  only  to 
assist  the  healing  process,  but  to  diminish  the  suffering. 
Cleansing  solutions  of  borax  (gr.  iv-lj),  bicarbonate  of  sodium 
(gr.  v-!j)  are  very  useful  to  detach  the  layers  of  pus  which 
cover  not  only  the  ulcerations,  but  the  adjoining  parts. 
When  this  has  been  done  thoroughly,  a  spray  of  four  per 
cent,  solution  of  cocaine  is  used  to  counteract  the  slight  in- 
flammatory exacerbation  set  up  by  the  spray,  and  to  slightly 
anaesthetize  the  larynx  prior  to  the  next  application,  which 
should  be  made  at  once.  lodoform  is  generally  recommended, 
but  I  have  not  found  it  as  effective  as  a  one  hundred  and 
twenty  grain  solution  of  nitrate  of  silver,  applied  to  each 
ulceration  only,  with  a  curved  probe,  covered  at  the  tip  with 
a  thin  film  of  cotton.  The  laryngoscope  should,  of  course,  be 
used.  When  the  practitioner  finds  this  measure  difficult, 
iodoform  may  be  used  with  the  insufflator  (Fig.  25).  When 
cicatrization  follows  upon  extensive  ulceration,  the  adhesions 
formed  may  be  of  such  a  nature  as  to  render  tracheotomy 
and  the  permanent  wearing  of  a  tube  necessary. 

Cicatricial  bands  not  admitting  of  dilatation,  they  should 
be  divided  when  such  division  can  restore  the  function  of  a 
part.  An  incision  through  a  web  connecting  a  portion  of 
the  edges  of  the  vocal  bands,  for  instance,  will  restore  the 
voice  and  free  respiration.  Frequently,  the  motion  of  the 
epiglottis  is  restrained  by  a  band  passing  from  its  edge  to 
the  ary-epiglottic  fold;  an  incision  through  this  band  not 
only  restores  free  motion  to  the  epiglottis,  but  renders  de- 
glutition, which  before  was  performed  with  difficulty,  per- 
fectly easy.  The  larynx  is  placed  under  the  influence  of  a 


356  DISEASES   OF   THE   LARYNX. 

ten  per  cent,  solution  of  cocaine,  and  the  cicatricial  tissue 
is  severed.  To  prevent  reunion  of  the  cut  edges,  a  probe 
must  be  passed  between  them  every  day  until  they  are  com- 
pletely healed. 


PLATE  vm. 


PLATE   VIII. 

LARYNGOSCOPICAL    APPEA11ANCE     OF    THE     LARYNX, 
NORMAL   AND   DISEASED.* 


FK;.  i. 

FIG.  2. 

Fir..  3. 

FIG.  4. 

J.    Epiglottis. 
r.    Ventricular  band. 
/.  Vocal  band. 
s.  Trachea. 

Omega-shaped  epiglot- 
tis    concealing      anterior 
portion  of  larynx. 

Depressed        epiglottis 
concealing    two-thirds  of 
larynx. 

I1.  Glosso-epiglottic  fold. 
1%  Palato-       "            " 
j.   Epiglottis. 
V.   Pyriform  sinus. 

m.  Cartilage  of  Wrisberg 
d.   Cartilage  of  Santorini. 
g.  Inter-arytenoid     com- 
missure. 

FIG.  6. 
SUBACUTE  LARYNGITIS. 
Female,a;t.47.   Infiltra- 
tion; threatening  oedema. 

FIG.  7. 
ACUTE  LARYNGITIS. 
Female,  set.  24.     Acci- 

g.   Inter-arytenoid     com- 
missure. 
w.  (Esophagus. 
y.   Posterior  wall  of  phar- 
ynx. 

FIG.  5. 
SUBACUTE  LARYNGITIS. 
Female,  opera    singer. 

di.      Solution    of    buchu 
and  uva  ursi. 

ammonia;.       Spontaneous 
resolution.      Case     refer- 
red by  Dr.  M.  Hanly. 

FIG.  8. 
CEDEMA  OF  LARYNX. 

set.   25.     Rest,  cocaine  2 

Complete  closure  of  the 

percent,  spray,  coca  wine 

tlG.   10. 

fives. 

COMPLICATED    WITH    PA- 

FIG. ii. 

FIG.  12. 

FIG.  9. 
CHRONIC  LARYNGITIS. 
Female,  aet.    36,  opera 
singer.   Coppersulph.  sol. 

RALYSIS   OF    THE    ARYTE- 
NOIDEUS. 

Male,  ax.  28.     Locally, 
zinc  (gr.  iv-Sj.),  alterna- 
ting with  nitrate  of  silver. 
Sol.    (gr.    6o-Sj.)    iodide 

Male,  set.  22.  Stone-cut- 
ter.    Removed  with  for- 
ceps, and  cauterized  base 
with  galvano-cautery. 

PAPILLOMA  OF  LARYNX. 

Female,  aet.  5.    Trache- 
otomy.    Extirpation  with 
forceps  and  snare. 

locally,  coca  wine  inter- 
nally and  lozenge  No.   i. 
Case     referred     by     Dr. 

of  potassium   internally; 
electricity  afterwards. 

FIG.  15. 
ABDUCTOR    PARALYSIS, 

Fig.  16. 

PARALYSIS     OF    ABDUC- 

>te. 

RIGHT    SIDE,   DURING    IN- 

FIG. 13. 
FIBROMA  OF   LEFT  VO- 
CAL BAND. 

Male,aet.63.    Removed 

FIG.  14. 
FIBROMA   OF   RIGHT   VO- 
CAL BAND. 

From  Mackenzie. 

SPIRATION. 

Female,  set.  48.    Strych- 
nia and  iodide  of  potas- 
sium.    Electricity. 

SIDE.      BAND   IN   CADAVE- 
RIC POSITION.     SHOWN  IN 
ATTEMPTED  PHONAT1ON. 

Female,  set.  61.     Due  to 
pressure   of  goitre    upon 

with  forceps. 

FIG.  18. 

right  recurrent. 

FIG.  17. 
PARALYSIS  OF  THYRO- 
ARYTENOID  MUSCLES. 
Female,  set.  35.    Singer. 
Rest  and  electricity. 

BILATERAL    ABDUCTOR 
PAKALYSIS       OF      SEVF.N 
YEARS'   STANDING. 
Male,  set.  47.       Treat- 
ment      proved      useless. 
Patient  refuses  tracheot- 
omy. 

tiG.  19. 

TUBERCULOUS       LARYN- 
GITIS. 

Female,  set.  24,  sprays, 
morphia,  etc.      Case  re- 
ferred   by    Prof.    S.     D. 
Gross. 

FIG.  20. 
TUBERCULOUS      LARYN- 
GITIS. 

Male,  aet.    50.     Sprays 
morphia,    iodoform,    and 
ether.     Case   referred  by 
Prof.  S.  D.  Gross. 

FIG.  21. 

TUBERCULOUS       LARYN- 
GITIS. 

Male,   set.    27.       Same 
treatment  as  Fig.  20.  Case 
referred  by  Dr.  Valette. 

FIG.  22. 
SYPHILITIC  LARYNGITIS. 
Male,  aet.  24.     Mercuri- 
als and  iodides,  nitrate  of 
silver  locally.      Case  re- 
ferred by  Dr.  Mercur. 

FIG.  23. 
SYPHILITIC  LARYNGITIS. 
Female,  aet.  27.     Mercu- 
rials, iodides.      Case  re- 
ferred by  Dr.  Minich. 

FIG.  24. 
CANCER  OF  THE  LARYNX. 
Epithelioma      of      left 
ventricular  band.      From 
Mackenzie. 

*  Represented  as  seen  by  gas-light.     By  day-light,  the  red  color  appears  much  paler. 


Plate  VIIL 


Sajous,  Pinx.it 


LITH.PMILA. 


CHAPTER  XXVII. 

DISEASES   OF  THE  LARYNX — (Continued.} 


NEUROSES. 
MOTOR    PARALYSIS. 

Etiology  and  Pathology. — Motor  paralysis  of  the  larynx 
may  be  limited  to  one  muscle  or  a  pair  of  muscles,  or  involve 
several  of  them  at  once.  It  may  be  accompanied  by  paralysis 
of  sensation.  It  may  be  limited  to  one  side  of  the  larynx — 
unilateral  paralysis — or  it  may  involve  both  sides — bilateral 
paralysis.  The  paralysis  may  be  limited  to  the  larynx  or 
include  the  surrounding  parts. 

The  causes  of  motor  paralysis  of  the  larynx  may  be  divided 
into  four  classes  :  (1)  disease  or  injury  of  the  brain,  involving 
the  cerebral  portion  of  the  nerves  which  supply  the  larynx ; 
(2)  injury  of,  or  pressure  upon  those  nerves  after  they  have 
left  the  cranial  cavity;  (3)  an  abnormal  condition  of  the 
muscles  themselves,  through  which  their  contraction  is  pre- 
vented; (4)  a  general  systemic  dyscrasia,  through  which  the 
laryngeal  muscles  are  debilitated  and  unable  to  respond  to 
nervous  influence. 

The  pneumogastric  nerve,  which  supplies  innervation  to 
the  larynx,  arises  on  the  floor  of  the  fourth  ventricle,  where 
it  lies  in  close  contact  with  the  origin  of  the  spinal  ac- 
cessory and  the  glosso-pharyngeal  nerves.  Its  filaments, 
after  running  downward  and  outward  through  the  substance 
of  the  medulla  oblongata,  finally  emerge  and  unite  into  a 
single  cord,  which  passes  out  of  the  cranium  through  the 
jugular  foramen,  immediately  beneath,  in  company  with 

(357) 


358  DISEASES   OF   THE   LAEYNX. 

the  spinal  accessory  nerve,  and  close  to  the  glosso-pharyn- 
geal,  which  passes  out  of  the  same  foramen,  but  is  separated 
from  its  companions  by  a  membranous,  sometimes  bony, 
partition. 

The  experiments  of  Longet  have  demonstrated  that  the 
pneumogastric  is,  at  its  origin,  exclusively  a  sensory  nerve, 
and  that  its  motor  properties  are  obtained  principally  through 
its  inosculation  with  the  spinal  accessory,  after  leaving  the 
medulla.  If,  therefore,  its  function  is  interfered  with  at  its 
origin  by  any  abnormal  condition,  the  symptoms  will  con- 
sist, in  the  larynx,  of  perverted  sensibility  or  anaesthesia ; 
but  the  close  proximity  of  the  roots  of  the  spinal  acces- 
sory, which  is  a  motor  nerve,  renders  the  occurrence  of 
anaesthesia  of  the  larynx  from  such  a  cause  very  rare,  the 
pathological  process  involving  both  roots  conjointly  in  the 
majority  of  cases,  if  not  at  the  outset  of  the  local  disturb- 
ance, at  least  very  soon  after.  The  same  reason  holds 
good  for  the  corresponding  nerve,  the  proximity  of  both 
pneumogastrics  explaining  the  fact  that  in  laryngeal  pa- 
ralysis of  central  origin,  the  paralysis  is  usually  bilateral. 
Again,  the  fact  that  the  glosso-pharyngeal  also  arises  in 
close  proximity,  explains  the  frequent  occurrence  of  pa-, 
ralysis  of  the  parts  to  which  it  is  distributed,  in  connection 
with  laryngeal  paralysis  of  cerebral  origin.  The  intimate 
connection  of  the  roots  of  the  pneumogastric  with  the  me- 
dulla, furnishes  an  explanation  for  the  frequently  observed 
concomitant  symptoms  of  paralysis  occurring  in  remote 
portions  of  the  body.  Syphilis,  through  the  formation  of 
gummata,  is  probably  the  most  frequent  cause  of  laryngeal 
paralysis  of  cerebral  origin,  to  which  tumors,  apoplexy,  mul- 
tiple sclerosis,  progressive  bulbar  paralysis,  etc.,  may  be 
added. 

Upon  emerging  from  the  cranial  cavity,  the  pneumogastric 


MOTOR  PARALYSIS.  359 

nerve  presents  a  ganglionic  swelling,  the  "  jugular  ganglion," 
which  receives  filaments  from  the  facial,  the  hypoglossal, 
and  the  anterior  branches  of  the  first  and  second  cervical 
nerves.  Immediately  below  this  ganglion,  the  pneumogastric 
receives  an  important  branch  from  the  spinal  accessory, 
which  supplies  it  with  motor  fibres.  The  first  branch  of 
distribution  given  off  by  the  pneumogastric  after  leaving 
the  cranium,  is  the  superior  laryngeal  nerve,  which  passes 
downward  and  forward  to  the  side  of  the  pharynx,  and  there 
subdivides  into  two  smaller  branches — the  internal,  which 
passes  through  the  thyro-hyoid  membrane  into  the  larynx, 
and  is  distributed  to  its  mucous  membrane.  This  branch  is 
formed  of  fibres  of  the  pneumogastric  proper,  and  therefore 
supplies  sensation.  The  second  branch  of  the  superior  laryn- 
geal, the  external,  is  formed  of  fibres  of  the  spinal  accessory, 
which  have  become  intermingled  with  those  of  the  pneumo- 
gastric, and  is  therefore  a  moto'r  branch.  It  does  not  pene- 
trate the  laryngeal  cavity,  but  passes  alongside  of  it,  to  be 
distributed  to  the  thyro-cricoid,  thyro-epiglottic  and  aryteno- 
epiglottic  muscles,  the  only  muscles  not  supplied  by  the  in- 
ferior or  recurrent  laryngeal  nerve.  The  pneumogastric  then 
proceeds  downward  in  the  sheath  of  the  carotid  artery,  and  its 
next  branch  is  only  given  off  after  it  has  entered  the  cavity 
of  the  chest.  Here  an  important  difference  exists  in  the 
course  taken  by  this  inferior  or  recurrent  branch  on  the  two 
sides  of  the  body.  On  the  right,  the  pneumogastric  descends 
in  front  of  the  subclavian,  and  its  recurrent  branch  passes 
beneath  that  artery  and  over  the  apex  of  the  right  lung 
which  lies  under,  and  ascends  obliquely  towards  the  groove 
between  the  trachea  and  the  oesophagus,  until  it  reaches 
the  larynx,  passing  behind  the  articulation  of  the  thyroid 
and  cricoid  cartilages,  where  it  joins  the  superior  laryngeal. 
On  the  left  side  the  pneumogastric  is  longer  and  passes  in 


360  DISEASES   OF   THE   LARYNX. 

front  of  the  arch  of  the  aorta,  and  gives  off  its  recurrent 
branch  when  opposite  its  lower  curve.  This  recurrent  branch 
winds  around  the  aorta,  and  when  behind  it,  ascends  also  in 
the  groove  between  the  oesophagus  and  the  trachea,  to  be 
distributed  to  the  left  side  of  the  larynx,  in  the  same  man- 
ner as  the  opposite  nerve.  Being  given  off  from  the  pneu- 
niogastric  nearer  the  median  line  of  the  body  than  on  the 
left  side,  it  does  not  approach  so  closely  the  apex  of  the 
left  lung  as  its  partner  does  that  of  the  right. 

The  length  of  the  pneumogastric  nerve,  and  the  relative 
position  which  it  occupies  throughout  its  entire  course  after 
emerging  from  the  skull,  causes  it  to  be  greatly  exposed  to 
pressure  as  soon  as  any  of  the  surrounding  structures,  vessels, 
glands,  etc.,  undergo  a  pathological  process  which  induces 
temporary  or  permanent  increase  in  size.  From  the  inferior 
surface  of  the  cranium  down  the  chest,  it  is  sufficiently  close 
to  the  large  vessels  of  the  neck  to  become  compressed  by  even 
a  small  aneurism,  anywhere  from  the  internal  carotid  above  to 
the  aorta  below,  on  the  left  side,  and  to  the  subclavian  on  the 
right.  Enlarged  cervical  glands,  tumors  of  any  kind,  bron- 
chocele,  wounds  with  the  point  of  a  sharp  instrument,  sever- 
ing the  nerve  or  including  it  in  a  ligature  during  an  operation, 
were  the  causes  of  some  of  the  reported  cases  of  laryngeal 
paralysis  due  to  lesion  of  the  pneumogastric  nerve  in  its 
course  along  the  neck. 

The  effect  upon  the  larynx  of  any  lesion  arresting  the 
function  of  the  pneumogastric  immediately  below  the  cra- 
nium, which  naturally  induces  paralysis  of  both  superior  and 
inferior  laryngeal  nerves,  is  complete  cessation  of  all  motion 
and  partial  loss  of  sensation  on  one  side  of  the  larynx.  If 
the  lesion  is  below  the  origin  of  the  superior  laryngeal  nerve, 
the  paralysis  of  motion  is  confined  to  the  muscles  supplied 
by  the  inferior  laryngeal,  while  there  is  no  loss  of  sensation. 


MOTOR   PARALYSIS.  301 

The  position  of  the  superior  laryngeal  nerve  and  its  com- 
paratively short  length,  cause  it  to  be  but  seldom  involved 
in  neighboring  pathological  changes.  Its  close  proximity  to 
the  internal  carotid,  behind  which  it  passes,  exposes  it  to 
the  presence  of  an  aneurism  in  this  location ;  tumors  of  the 
pharynx,  or  enlarged  glands,  may  aft'ect  it  in  the  same 
manner.  Diphtheria  most  frequently  causes  impairment  of 
the  superior  laryngeal  nerve,  by  producing  organic  changes 
in  its  substance;  these  are  generally,  however,  of  but  tem- 
porary duration. 

Lesion  of  this  nerve  causes  partial  loss  of  sensation,  and 
paralysis  of  the  thyro-cricoid,  thyro-epiglottic,  and  ary- 
epiglottic  muscles  in  the  lateral  half  of  the  larynx.  The 
epiglottis  can  only  be  partially  closed,  while  extension  of 
the  vocal  band  is  prevented. 

Lesions  of  the  recurrent  laryngeal  nerve  are  the  most 
frequent  causes  of  paralysis  of  the  larynx.  On  the  left  side, 
its  close  connection  with  the  arch  of  the  aorta  causes  it  to 
be  greatly  exposed  to  pressure  by  aneurisms,  which  are 
frequent  in  this  situation;  the  left  carotid  and  the  sub- 
clavian  arteries  are  also  the  seat  of  aneurism  sometimes,  and, 
as  they  lie  behind  the  recurrent  branch,  add  to  the  danger 
of  compression  from  this  cause.  On  the  right  side,  aneu- 
rism of  the  innominate  or  of  the  subclavian  and  carotid, 
may  also  cause  pressure,  but  this  occurs  much  less  often 
than  on  the  left  side.  The  close  proximity  of  the  apex  of 
the  right  lung  furnishes  another  source  of  compression, 
through  expansion  or  thickening  of  its  parenchyma.  On 
the  left  side,  the  nerve  does  not  lie  so  closely  to  the  lung, 
but  is  more  exposed  to  pressure  from  bronchial  glands,  and 
other  mediastinal  growths  and  hardened  masses  of  connective 
tissue. 

An   aneurism  of  large   size  may  exert  pressure   on  both 


302  DISEASES    OF   THE   LA11YNX. 

recurrent s  and  cause  bilateral  paralysis.  As  the  nerves 
ascend,  they  gradually  approach  the  oesophagus,  carcinoma 
of  which  may  induce  pressure  on  one  or  both  nerves. 
Another  cause  of  bilateral  recurrent  paralysis,  is  enlarge- 
ment of  the  thyroid  gland,  or  bronchocele,  which  fills  up 
the  grooves  between  the  trachea  and  oesophagus,  compress- 
ing the  recurrents  which  lie  within  them. 

The  effect  of  pressure  upon  the  recurrent  laryngeal  nerves, 
should  be,  in  all  cases,  paralysis  of  all  the  motor  muscles  of 
the  larynx,  except  the  depressors  of  the  epiglottis  and  the 
thyro-cricoid  muscles,  wdiich  are  supplied  by  the  superior 
laryngeal.  The  prevailing  opinion,  at  present,  is  that  this  is 
only  the  case  when  the  lesion  is  of  such  a  nature  as  to  com- 
pletely annul,  either  by  great  pressure,  solution  of  continuity 
or  disorganization,  the  conduction  of  nerve  power.  Felix 
Semon,  of  London,  has  advanced  the  opinion,  supported  by 
a  large  number  of  autopsies,  that  in  all  cases  of  organic 
disease  or  injury  of  the  motor  nerves  of  the  larynx,  there  is 
either  paralysis  of  the  abductor  muscles  alone,  or  these 
muscles  are  affected  earlier  and  more  severely  than  any 
others ;  and  that,  if,  in  a  case  in  which  both  the  abductors 
and  adductors  are  affected,  recovery  takes  place,  the  adduc- 
tors are  apt  to  recover  first  or  exclusively.  This  would  seem 
to  indicate  a  greater  amount  of  vitality,  if  we  may  so  call  it, 
in  the  adductor  than  in  the  abductor  fibres,  this  vitality 
enabling  the  former  to  resist  the  pathogenic  causes  longer 
and  to  recover  sooner  than  their  antagonistic  fibres,  which 
are  easily  influenced  and  the  recuperative  powers  of  which 
are  much  wreaker.  This  explains  the  much  greater  rela- 
tive frequency  of  abductor  than  adductor  paralysis.  Later 
experiments  by  F.  H.  Hooper,  of  Boston,  however,  indicate 
that  Semon's  theory  can  only  be  fully  accepted,  as  yet, 
with  reserve. 


MOTOR  PARALYSIS.  363 

Paralysis  of  the  laryngeal  muscles  is  frequently  brought 
about  by  an  inflammatory  infiltration  of  their  substance. 
This  is  evidenced  by  the  loss  of  voice  attending  some  cases 
of  subacute  laryngitis.  After  a  few  days  of  hoarseness,  in 
which  the  inflammatory  process  is  limited  to  the  surface,  the 
voice  becomes  monotonous,  in  the  true  sense  of  the  word, 
the  extension  of  the  inflammatory  process  to  the  smaller 
fasciculi  of  the  thyro-arytehoid  muscles  rendering  them 
unable  to  contract  and  to  modify  the  pitch  of  the  voice. 
The  frequency  of  this  monotonous  voice  in  the  course  of 
even  so  slight  an  affection  as  subacute  laryngitis,  seems  to 
indicate  that  the  laxors,  or  vocal  muscles,  are  easily  influ- 
enced by  surrounding  inflammatory  processes  and  that  they 
are  frequently  paralyzed.  This,  however,  cannot  be  con- 
sidered as  a  true  paralysis  of  these  muscles,  but  a  paresis  of 
temporary  duration. 

Atrophy  or  degeneration  of  the  muscles  themselves,  is 
another  cause  of  motor  paralysis.  It  is  generally  secondary, 
however,  to  some  lesion  affecting  the  nerve  supply,  although 
idiopathic  changes  may  occur  in  the  muscles  independently 
of  nerve  lesions.  The  abductor  muscles,  the  posterior  crico- 
arytenoidei,  appear  to  be  the  most  prone  to  myopathic 
changes,  the  adductors,  when  they  take  part  in  the  palsy, 
only  losing  their  power  after  them. 

A  number  of  abnormal  conditions  of  the  general  system, 
anaemia,  rheumatism,  syphilis,  general  poisoning  through  the 
use  of  various  drugs,  opium,  belladonna,  mercury,  arsenic, 
etc.,  or  through  the  continued  inhalation  or  absorption  of 
phosphorus,  lead  or  arsenic,  are  occasional  etiological  fac- 
tors in  the  production  of  motor  paralysis.  The  excessive 
use  of  alcoholic  beverages  is  another,  but  more  frequent 
cause,  according  to  Morgan,  of  "Washington.  With  the  excep- 
tion of  the  diatheses  named,  however,  true  paralysis,  occur- 


304  DISEASES   OF  THE  LARYNX. 

ring  as  a  result  of  these  conditions,  is  rarely  seen,  the  local 
trouble  consisting  more  of  a  paresis  of  temporary  duration, 
which  ceases  some  time  after  the  discontinuance  of  exposure 
to,  or  the  use  of,  the  toxic  agent. 

Paralysis  of  Abduction. — As  we  have  seen,  abduction  of 
the  vocal  bands  is  performed  solely  by  the  posterior  crico- 
arytenoid  muscles,  which  approximate  the  posterior  angles 
of  the  arytenoid  cartilages,  causing  wide  separation  of  their 
anterior  or  vocal  processes.  If  one  of  these  muscles  is  par- 
alyzed, therefore,  we  will  have  unilateral  paralysis  of  abduc- 
tion, and  the  vocal  band  will  be  seen  in  the  mirror  to  remain 
in  adduction,  i.e.,  parallel  with  the  median  line  of  the  glottis. 
The  subjective  symptoms  of  this  condition  are  so  slight  that 
they  rarely  attract  attention.  This  is  due  to  the  fact  that 
the  breathing  space  left  between  the  healthy  vocal  band 
and  the  motionless  one  is  sufficiently  great  for  ordinary 
breathing,  while  the  approximation  of  the  former  to  the 
latter,  and  the  fact  that  paralysis  of  the  thyro-arytenoidei 
muscles  does  not  exist  to  interfere  with  modulation,  causes 
the  voice  to  be  unaffected.  Upon  great  exertion,  however, 
some  dyspnosa  may  be  experienced,  the  abnormal  size  of 
the  glottis  preventing  the  access  of  a  sufficiently  great 
amount  of  air  to  the  lungs. 

When  both  posterior  crico-arytenoid  muscles  are  paralyzed, 
the  symptoms,  instead  of  being  hardly  noticeable,  are  of  the 
gravest  nature,  owing  to  the  constant  and  almost  complete 
approximation  of  both  vocal  bands.  A  mere  slit,  hardly 
more  than  a  line  wide  posteriorly,  which  represents  the  field 
of  action  of  the  arytenoideus,  is  the  extent  of  the  breathing 
space,  which,  during  inspiration,  is  still  more  reduced  by 
the  pressure  of  the  air  current  upon  the  horizontal  sur- 
faces of  the  vocal  bands.  In  expiration,  the  contrary  is  the 
case ;  the  outgoing  current  forces  the  bands  apart,  their 


PAKALYSIS  OF  ABDUCTION.  365 

inferior  surface  gradually  sloping  down  towards  the  side  of 
the  trachea,  and  presenting  therefore  no  flat  surface  upon 
which  the  expired  current  can  impinge.  The  respiration 
is  consequently  greatly  impeded,  labored  and  frequently  noisy 
in  inspiration,  and  suffocation  is  likely  to  take  place  at  any 
moment,  especially  during  one  of  those  spasmodic  attacks  of 
inspiratory  dyspnoea  to  which  these  cases  are  subject, 
unless  precautionary  tracheotomy  has  previously  been  per- 
formed. The  voice,  however,  is  unimpaired,  the  complete 
approximation  of  the  vocal  bands  being  performed  by  the 
arytenoideus  muscle. 

Paralysis  of  the  posterior  crico-arytenoid  muscles  when  bi- 
lateral, must  of  necessity  be  due  to  some  condition  implicating 
simultaneously  the  nervous  supply  of  both  sides.  The  causes 
must  therefore  reside  in  the  brain  centres  or  in  the  recurrent 
laryngeals,  the  pneumogastric  nerves  being  too  far  apart, 
from  their  exit  from  the  cranium  down  to  where  they  give 
off  their  recurrent  branches,  to  become  simultaneously  in- 
volved. In  the  brain,  a  tumor,  for  instance,  in  the  neigh- 
borhood of  the  fourth  ventricle  or  in  the  medulla,  may  cause 
pressure  upon  the  roots  of  the  pneumogastric  and  spinal 
accessory,  paralysis  of  the  abductor  muscles  occurring  in 
that  case,  according  to  Semon,  as  the  first  manifestation  of 
a  lesion,  to  be  followed,  as  the  tumor  increases,  by  paralysis 
of  all  the  muscles  of  the  larynx.  Degeneration  of  the  same, 
gives  rise  to  the  same  train  of  symptoms.  When  a  cerebral 
lesion  is  the  initial  cause,  general  concomitant  symptoms 
are  more  or  less  evident.  The  recurrent  laryngeal  nerves, 
as  we  have  seen,  can  be  compressed  simultaneously  by 
aneurisms,  cancer  of  the  oesophagus  and  bronchoceles. 

The  lesion  may  be  located  in  the  muscles  themselves, 
through  disintegration  of  their  substance  by  syphilitic 
ulceration,  or  a  continued  inflammatory  process  may  cause 


3GG  DISEASES    OF   THE   LARYNX. 

them  to  assume  a  scirrhotic-like  degeneration  through  im- 
paired nutrition.  A  general  toxaemia,  such  as  that  by  lead, 
arsenic,  etc.,  as  we  have  seen,  may  also  cause  it,  the  lesion 
being  probably  located,  as  suggested  by  Bosworth,  in  an 
independent  nerve-centre,  which  presides  over  the  functions 
of  these  muscles. 

Unilateral  paralysis  may  result  from  a  brain  lesion  and 
occur  as  the  precursor  of  a  forthcoming  bilateral  palsy  of 
central  origin.  Unlike  in  bilateral  paralysis,  it  may  be  due 
to  a  lesion  of  the  pneumogastric  nerve  proper,  in  addition 
to  the  causes  of  bilateral  paralysis,  wounds,  glandular  swell- 
ings of  the  neck,  etc.,  which  can  hardly  cause  bilateral 
paralysis;  to  these  may  be  added,  if  on  the  right  side,  the 
proximity  of  the  apex  of  the  lung,  and  on  the  left,  medias- 
tinal  tumors. 

Paralysis  of  Adduction — Adduction  of  the  vocal  bands 
being  performed  by  the  lateral  crico-arytenoid  muscles, 
which  draw  the  posterior  angles  of  the  arytenoid  cartilages 
outward  and  cause  the  vocal  bands  to  approach  one  another, 
paralysis  of  these  muscles  causes  the  vocal  bands  to  remain 
in  a  state  of  extreme  abduction.  This  condition  is  in  most 
cases  due  to  hysteria  (hysterical  aphonia,  which  will  be 
described  later  on)  and  chlorosis,  inducing  weakness  of  the 
muscles  through  defective  nutrition;  rheumatism,  either 
involving  the  muscles  proper  or  the  crico-thyroid  joint, 
catarrhal  inflammation,  especially  following  a  strain  of  the 
muscles  in  vociferating  or  screaming;  injury,  such  as  that 
caused  by  a  firm  grasp  of  the  throat  with  the  fingers ;  general 
poisoning  by  lead  or  arsenic,  are  among  the  causes  cited. 
That  adductor  paralysis,  either  unilateral  or  bilateral,  can 
be  due  to  pressure  upon  the  recurrent  laryngeal  without 
involving  the  other  muscles  of  the  larynx  supplied  by  that 
nerve,  seems  to  be  very  doubtful,  and  I  am  inclined  to 


PARALYSIS  OF  ADDUCTION.  367 

believe  that  in  the  cases  reported  with  such  an  etiology,  the 
bands  were  not  in  extreme  adduction,  but  in  the  cadaveric 
position,  an  error  quite  possible  if  we  note  the  slight  dif- 
ference between  the  two  positions  and  the  comparatively 
limited  degree  of  abduction  in  some  individuals. 

If  bilateral  paralysis  of  the  adductors  exist,  the  vocal 
bands  will  appear  in  the  mirror,  separated  to  the  utmost 
degree.  The  voice  is  completely  lost,  and  the  ability  to 
cough  or  "hem"  is  also  destroyed.  If  the  patient  tries  to 
whisper,  a  marked  loss  of  breath,  occasioning  great  fatigue, 
accompanies  his  almost  inaudible  words. 

In  unilateral  paralysis,  one  band  only  is  seen  to  be  in  ex- 
treme adduction,  and  when  an  effort  is  made  to  sound  the 
voice,  the  band  on  the  normal  side  is  seen  to  pass  beyond 
the  median  line  and  to  approach  as  nearly  as  possible  to  its 
motionless  companion.  Although  aphonia  also  exists,  the 
whispering  is  much  more  audible,  and  the  phonative  loss  of 
breath,  as  it  was  termed  by  Ziemssen,  is  much  less  great. 

To  the  form  of  paralysis  of  adduction  above  described, 
may  be  added  paralysis  of  the  arytenoideus  muscle,  which, 
however,  is  seldom  affected  singly,  notwithstanding  its  ex- 
posed position  between  the  arytenoid  cartilages.  Its  object 
being  to  approximate  the  portion  of  the  vocal  bands  behind 
the  vocal  processes,  its  paralysis  prevents  this  action,  and, 
although  the  bands  are  approximated  in  the  anterior  three- 
fourths  of  the  glottis,  a  triangular  space  is  left  behind  the 
vocal  processes,  through  which  air  escapes  during  phonation. 
The  voice  is  either  completely  lost,  or  so  weak  as  to  be  hardly 
audible.  In  strong  individuals,  however,  it  may  be  com- 
paratively strong,  the  phonative  loss  of  breath  being  marked. 
It  may  be  caused  by  catarrhal  inflammation,  or  occur  in  the 
course  of  a  local  ulcerative  process.  Hysteria  is  also  an 
occasional  cause. 


368  DISEASES   OF   THE   LARYNX. 

Paralysis  of  Tension. — Two  forms  of  paralysis  of  tension 
may  be  met  with :  that  due  to  paralysis  of  the  thyro-cricoid 
muscles,  which  is  of  rare  occurrence,  arid  that  due  to  paralysis 
of  the  thyro-arytenoidei,  which  is  of  frequent  occurrence. 
Both  may  be  unilateral  or  bilateral.  The  object  of  the 
thyro-cricoid  muscles  being  to  extend  the  vocal  bands  by 
raising  the  anterior  portion  of  the  cricoid  ring,  as  demon- 
strated by  Hooper,  of  Boston,  arid  thus  cause  the  arytenoid 
cartilages,  which  are  supported  on  the  upper  edge  of  its  seal- 
like  portion,  to  draw  on  them,  paralysis  of  these  muscles 
causes  the  bands  to  remain  in  a  relaxed  condition.  Instead 
of  appearing  tense  and  straight,  they  present  a  wavy  line, 
their  edges  touch  irregularly,  and  some  parts  of  the  bands 
are  higher  than  others.  During  respiration  they  are  some- 
times seen  to  be  influenced  by  the  respiratory  current, 
being  depressed  in  inspiration  and  slightly  bulged  out  in 
expiration.  The  voice  is  coarse,  and  remains  in  the  same 
pitch ;  slight  dyspnoea  sometimes  exists.  The  causes  of  this 
affection  are  generally  traceable  to  -direct  injury  to  the 
muscles,  choking  with  the  ringers,  blows  in  the  neck,  cuts, 
etc.  It  may  also  occur  as  a  result  of  diphtheria,  through 
organic  change  in  the  substance  of  the  superior  laryngeal 
nerve,  or  be  due  to  some  pressure  upon  the  latter.  In  this 
case,  however,  it  is  associated  with  partial  loss  of  sen- 
sation in  the  larynx  and  paralysis  of  the  depressors  of  the 
epiglottis. 

In  the  second  form  of  paralysis  of  tension,  or  paralysis  of 
the  thyro-arytenoid  muscles,  I  believe  the  lesion  to  be  limited 
to  the  fasciculus  lying  parallel  with,  and  close  to  the  vocal 
band.  Its  object  being  to  approximate  its  points  of  attach- 
ment, the  anterior  angle  of  the  arytenoid  cartilage  and  the 
retiring  angle  of  the  thyroid  cartilage,  it  is  in  a  state  of 
constant  tension.  When  paralyzed,  however,  this  state  of 


PAEAL1SIS   OF   ABDUCTION,   ADDUCTION   AND   RELAXATION. 

tension  ceases,  and  the  muscle  is  subject  to  the  lateral  trac- 
tion of  the  diverging  fibres  of  the  second  fasciculus  which 
lies  alongside.  The  vocal  band  is  thus  caused  to  assume  a 
slight  curve,  especially  marked  in  the  centre,  where  the 
resistance  to  the  lateral  traction  is  least.  When  both  bands 
are  involved,  an  elliptical  space  can  be  seen  between  them 
during  phonation.  The  voice  is  husky,  high  and  weak,  the 
air  escaping  through  the  elliptical  space  and  necessitating 
great  effort  on  the  part  of  the  patient  to  produce  sound. 
He  therefore  tires  quickly,  a  few  phrases  being  a  task. 

The  causes  of  this  form  of  palsy  are  essentially  local,  and 
consist  principally  in  prolonged  or  excessive  use  of  the 
voice,  straining  in  trying  to  attain  notes  above  its  compass, 
screaming  and  shouting.  It  may  also  be  due  to  catarrhal 
inflammation,  this  being  occasioned  generally  by  using  the 
voice  during  the  attack  of  subacute  laryngitis. 

Paralysis  of  Abduction,  Adduction  and  Relaxation. — The 
three  forms  of  paralysis  so  far  considered,  may  occur 
together,  and  involve  either  one  side  of  the  larynx  or  both. 
The  terms  "general"  or  "complete"  paralysis  would  seem 
more  adequate  to  express  this  condition,  but  as  paralysis 
of  abduction,  adduction  and  relaxation  can,  r.nd  most 
frequently  does,  occur  without  involvement  of  the  superior 
laryngeal  nerve,  which  supplies  the  thyro-cricoidei  and  the 
depressors  of  the  epiglottis,  such  terms  would  not  express 
the  true  condition  in  the  majority  of  cases,  since,  as  we 
have  seen,  complete  paralysis  of  the  larynx  can  only  occur 
when  the  lesion  is  in  the  brain,  or  if  below  the  cranium, 
above  the  superior  laryngeal  branch.  The  abductors  and 
adductors  being  involved,  the  bands  are  not  subject  to  the 
action  of  either,  and  remain  midway  between  adduction 
and  abduction,  i.e.,  in  the  cadaveric  position.  Paralysis  of 
the  laxors  of  the  vocal  bands  existing  also,  we  should  have 

24 


370  DISEASES   OF   THE   LARYNX. 

the  characteristic  elliptical  glottis,  but  such  is  not  the  case ; 
the  second  fasciculus  of  the  thyro-arytenoid  being  also  in- 
volved in  the  palsy,  does  not  cause  lateral  traction  of  the 
vocal  band  by  means  of  its  diverging  fibres,  and  the 
evidence  of  paralysis  of  relaxation  does  not  appear  in  the 
laryngeal  image.  The  symptoms  accompanying  bilateral 
paralysis  are  of  course  complete  loss  of  the  voice,  this  being 
explained  by  the  immobility  of  the  bands.  Phonative  loss 
of  breath  is  a  marked  symptom  accompanying  efforts  at 
phonation.  The  differentiation  of  this  condition  from  that 
of  complete  paralysis  of  the  larynx,  lies  in  the  fact  that  in 
the  latter,  paralysis  of  the  thyro-  and  aryteno-epiglottic 
muscles  existing,  the  epiglottis  remains  upright  over  the 
larynx,  rendering  deglutition  difficult  and  dangerous,  this 
being  aggravated  by  the  partial  loss  of  sensation.  The 
thyro-cricoid  muscle  being  also  paralyzed,  extension  of  the 
bands  is  not  performed,  and  they  present  the  wavy,  relaxed 
appearance  described  under  the  heading  of  paralysis  of 
tension. 

The  lesion  giving  rise  to  the  bilateral  affection  must  be 
located,  as  we  have  seen,  in  a  region  where  the  motor  supply 
of  both  sides  can  be  implicated  at  the  same  time.  This 
being  possible  (except  by  the  merest  coincidence)  only  in 
the  course  of  the  recurrent  laryngeal  nerves,  aneurism  of 
the  arch  of  the  aorta,  carcinoma  of  the  oesophagus  and  bron- 
chocele,  are  the  affections  which  may  be  suspected  as  causa- 
tions in  a  given  case.  It  is  perhaps  unnecessary  to  repeat 
that  were  the  lesion  in  the  brain,  the  symptoms  accompanying 
paralysis  of  the  superior  laryngeal,  an  erect  epiglottis,  loss 
of  sensation,  etc.,  would  also  be  present. 

In  unilateral  paralysis  of  abduction,  adduction  and  relaxa- 
tion, one  band  only  is  seen  to  be  in  the  cadaveric  position. 
The  symptoms  accompanying  this  condition  vary  greatly 


TREATMENT  OF  MOTOR  PARALYSES.  371 

from  those  of  the  bilateral  paralysis,  being  hardly  perceptible 
in  some  cases.  The  paralyzed  band  lying  midway  between 
abduction  and  adduction,  it  is  sufficiently  near  the  middle 
line  to  be  easily  approached,  during  phonation,  by  the 
normal  band,  which  is  drawn  beyond  its  usual  limit  by  the 
healthy  muscles,  these  being  assisted  by  the  arytenoideus, 
which  assists  both  sides,  and  the  innervation  of  which  is 
compensated  by  the  healthy  side.  The  voice,  therefore,  may 
not  be  influenced  beyond  a  slight  hoarseness.  At  times, 
however,  the  compensatory  adduction  of  the  normal  band 
is  not  sufficient  to  approximate  the  pair,  and  the  voice  may 
be  impaired  or  lost,  the  phonative  loss  of  breath  being 
marked  and  causing  great  fatigue.  Respiration  is  some- 
times interfered  with,  especially  during  exertion.  In  this 
form  of  the  affection,  the  field  for  a  greater  variety  of  causes 
is  increased.  It  can  be  due,  in  addition  to  the  lesions  of 
the  recurrent  nerves,  to  some  lesion  of  the  pneumogastric 
from  below  the  superior  laryngeal  down  to  where  the  re- 
current laryngeal  is  given  off.  In  addition  therefore,  to 
aneurism  of  the  aorta  and  innominate,  carcinoma  of  the 
oesophagus  and  goitre,  we  may  have  pressure  upon  the  pneu- 
mogastric, induced  by  aneurisms  along  the  entire  course 
of  the  carotid  artery,  enlarged  cervical  glands,  tumors,  etc., 
the  number  of  possible  causes  being  further  augmented  by 
those  to  which  the  recurrent  nerves  are  separately  liable  in 
the  thorax,  such  as  pressure  from  the  indurated  apex  of 
the  lung,  etc.,  on  the  right,  and  aneurism  of  the  aorta,  etc., 
on  the  left,  the  majority  of  which  have  already  been  enu- 
merated. 

Treatment. — The  many  causes  of  motor  paralysis  of  the 
larynx  renders  an  exact  delineation  of  the  therapeutic 
measures  to  be  adopted  impossible.  Whatever  the  etiological 
factor  may  be,  however,  the  first  indication  is  to  treat  it, 


372 


DISEASES   OF   THE   LARYNX. 


and,  if  possible,  eradicate  it,  the  success  of  the  measures 
employed  depending1,  of  course,  upon  the  nature  of  the 
causative  affection  and  its  amenability  to  treatment.  In 
some  cases,  especially  when  the  laryngeal  symptoms  have 
not  been  of  long  duration,  an  amelioration  takes  place  as 
soon  as  the  disease  to  which  the  paralysis  is  due  begins  to 
yield  to  the  therapeutic  measures.  Frequently,  however, 
this  is  not  the  case,  and  measures  must  be  adopted  to  stimu- 
late the  laryngeal  muscles  to  action.  For  this  purpose, 
electricity  is  by  far  the  most  potent  agent.  For  its  applica- 
tion, Mackenzie's  laryngeal  electrode,  shown  in  Fig.  82,  may  be 


Mackenzie's  laryngeal  electrode. 

used.  This  being  connected  with  the  negative  pole  of  a  faradic 
battery,  its  extremity  is  introduced  into  the  larynx,  while  the 
positive  pole  is  connected  with  an  ordinary  surface  electrode 
which  the  patient  can  hold  over  the  larynx  externally,  or 
with  a  necklet  which  is  secured  around  his  neck.  The  ex- 
tremities of  both  electrodes  should  be  covered  with  sponge 
or  kid  to  prevent  the  stinging  that  is  produced  when  they  are 
uncovered,  and  thoroughly  wetted  before  each  application. 
The  manipulation  of  Mackenzie's  electrode  is  like  that  of 
the  ordinary  laryngeal  forceps,  the  mirror  being  employed 
to  note  and  conduct  the  localization  of  the  tip  of  the  in- 
strument. The  nearer  the  paralyzed  muscle  the  application, 


THEATMENT  OF  MOTOR  PARALYSES.  373 

the  better.  The  electrode  being  in  position,  the  finger-rest 
on  the  top  of  the  handle  is  depressed,  and  firm  pressure  is 
exerted  on  the  neck  by  the  other  electrode.  At  first,  this 
manipulation  is  quite  difficult  to  perform,  gagging  and 
retching  preventing  the  introduction  of  the  instrument. 
After  a  few  trials,  however,  the  parts  become  more  tolerant 
and  the  application  can  be  borne,  in  the  majority  of  cases, 
without  trouble.  Cocaine  is  of  great  assistance  in  difficult 
cases,  and  a  general  application,  with  a  cotton  pledget  or  an 
atomizer,  of  a  ten  per  cent,  solution,  will  anaesthetize  the 
parts  sufficiently  to  allow  free  manipulation  at  the  first 
sitting.  Each  application  should  last  but  a  few  seconds,  this 
being  repeated  several  times  at  intervals  of  a  couple  of 
minutes.  One  sitting  every  other  day  is  sufficient  in  most 
cases,  this  being  continued  until  the  return  of  the  voice. 
After  this  has  been  accomplished,  the  sittings  should  be 
gradually  decreased  in  number.  Mackenzie's  electrode  has 
been  modified  by  himself,  Fauvel,  Ziemssen  and  others,  so  as 
to  enable  both  poles  to  be  introduced  into  the  larynx.  No 
great  advantage  is  obtained  by  these  modified  instruments, 
however,  and  the  manipulation  is  rendered  much  more 
difficult. 

Electricity  may  also  be  applied  by  placing  one  pole  on 
each  side  of  the  larynx  externally.  Although  much  more 
easily  conducted,  this  method  of  application  is  not  nearly 
so  effective  as  when  one  of  the  poles  is  placed  in  the  larynx. 

Strychnia,  administered  internally  or  hypodermically,  the 
latter  being  the  most  effective,  is  a  valuable  adjuvant  to  the 
treatment  by  electricity.  It  may  be  administered  in  doses 
of  one-sixtieth  of  a  grain,  gradually  increased  until  one- 
twentieth  of  a  grain  is  administered,  the  injections  being 
given  two  or  three  times  a  week ;  if  prescribed  internally, 
it  can  be  taken  night  and  morning.  At  times  this  remedy 


*H4  DISEASES   OF   THE   LARYNX. 

is  very  effective ;  at  others,  it  produces  no  effect  whatever. 
General  measures,  calculated  to  invigorate  the  system,  are 
productive  of  much  good,  and  advance  the  recovery,  if  such 
can  take  place. 

HYSTERICAL   APHONIA, 

(Synonyms : — Hysterical    Paratysis  of  the   Yocal   Cords  :    Nervous 

Aphonia.) 

Etiology. — Hysterical  aphonia  is  due  to  a  paresis  of  the 
abductor  muscles,  occurring  independently  of  any  organic 
lesion,  either  of  the  muscles  themselves  or  their  nervous 
supply.  It  is  less  of  a  local  trouble  than  a  general  one, 
however,  consisting  more  of  an  inability  on  the  part  of  the 
patient,  through  some  momentary  disturbance  of  the  central 
co-ordinating  powers  to  approximate  the  vocal  bands  suf- 
ficiently to  make  a  sound,  than  a  true  loss  of  contractility 
of  the  muscular  fibres  or  conductivity  of  the  nerve  fibres. 
Shocks,  fear,  anger,  intense  excitement,  .etc.,  represent  one 
class  of  causes,  which,  occurring  simultaneously  with  weak- 
ened resisting  powers,  are  the  primary  element  in  a  large 
number  of  cases.  In  others,  no  evident  cause  is  apparent,  the 
voice  disappearing  suddenly  or  gradually,  sometimes  return- 
ing in  the  same  manner.  It  occasionally  occurs  as  a  manifes- 
tation of  a  remote  trouble,  especially  affections  of  the  uterus. 
Hysterical  aphonia  is  limited  to  the  period  between  the  at- 
tainment of  puberty  and  the  menopause,  occurring  most  fre- 
quently in  unmarried  women. 

Symptoms. — The  degree  of  aphonia  depends  upon  the  ex- 
tent to  which  the  vocal  bands  can  be  approximated.  In 
most  cases,  however,  there  is  complete  loss  of  voice.  In  a 
small  proportion,  even  the  power  of  whispering  is  lost, 
through  implication  of  the  diaphragm  in  the  paresis.  In 
some  cases,  although  the  patient  is  unable  to  speak,  she  may 


HYSTERICAL   APHONIA.  375 

be  able  to  sing  and  cough  loudly.  The  aphonia  is  sometimes 
intermittent,  disappearing  for  a  few  days  and  returning  after 
some  days  or  weeks  of  perfect  freedom.  Upon  examination 
with  the  laryngeal  mirror,  the  bands  are  seen  to  approach 
the  median  line  when  an  effort  is  made  at  phoiiation,  but, 
instead  of  remaining  together,  they  instantly  separate,  leaving 
an  open  space  between  them,  consisting  in  some  cases  of  a 
mere  slit,  and  in  others  of  a  large,  triangular  opening.  This 
peculiarity  of  suddenly  approaching  each  other,  is  a  char- 
acteristic of  hysterical  aphonia,  the  bands  being  either  per- 
fectly motionless  or  approximating  sluggishly  in  true  com- 
plete or  partial  paralysis. 

Treatment. — The  treatment  of  this  affection  consists  in  the 
local  application  of  electricity  and  the  internal  administra- 
tion of  nerve-stimulants  or  tonics.  The  electricity  can  be 
applied  as  explained  under  the  last  heading,  Morell  Mac- 
kenzie's laryngeal  electrode  being  employed.  Frequently 
the  first  application  causes  the  emission  of  sound  for  a 
few  moments;  in  such  cases,  the  progress  is  very  rapid, 
and  the  voice  soon  returns.  In  some,  however,  weeks 
and  even  months  are  necessary,  while  in  others,  especially 
in  cases  of  long  duration,  where  atrophy  of  the  muscles 
may  have  resulted  from  prolonged  inactivity,  no  benefit  is 
afforded.  Of  nerve  stimulants,  valerian,  in  the  form  of  the 
elixir  of  valerianate  of  ammonia,  is  probably  the  most  effec- 
tive, a  teaspoonful  being  given  night  and  morning.  The 
valerianate  of  zinc  is  another  excellent  preparation,  one 
grain  being  administered  every  four  hours.  "When  anaemia 
exists,  which  is  frequently  the  case  in  this  affection,  Rabu- 
teau's  pills,  one  after  each  meal,  are  productive  of  good 
results.  Wine  of  coca  seemed  to  be  the  only  efficacious 
agent  in  one  of  my  cases,  all  other  means  having  failed. 
Nerve  tonics,  strychnia,  mix  vomica,  arsenic,  and  quinia  are 
of  great  assistance  in  some  cases. 


376  DISEASES   OF   THE   LAEYNX. 

SPASM    OF   THE   LAKYNX. 

(Synonyms  :  — Spasm    of  the    Glottis  ;     Laryngismus    Stridulus  ; 
Spasmodic    Croup.) 

Etiology. — This  is  an  affection  of  young  children,  occurring 
most  frequently  during  the  period  of  first  dentition.  A 
powerful  predisposing  cause  is  scrofula,  especially  when 
rickets  is  present.  It  is  most  common  in  bottle-fed  children, 
and  is  often  caused  by  injudicious  nourishment,  by  allowing 
them  to  partake  of  food  which  their  stomach  is  not  yet  able 
to  digest.  Children  brought  up  in  cities,  and  especially 
those  who  are  kept  in-doors  almost  always,  are  much  more 
prone  to  it  than  those  who  live  in  the  country  and  are  in 
the  open  air  most  of  the  time.  The  affection  is  occasionally 
seen  in  adults.  Spasm  of  the  larynx  may  be  due  to  the 
presence  of  a  foreign  body,  or  occur  as  a  result  of  pressure 
upon  some  motor  nerve. 

Pathology. — The  prevailing  theory  is  that  of  Marshall  Hall, 
who  ascribed  the  affection  to  remote  disturbances,  operating 
reflexly  upon  the  larynx.  In  teething,  he  believed  that  the 
impression  was  transmitted  through  the  trifacial;  in  ill- 
nourished  infants,  through  the  pneumogastric,  etc. 

Symptoms. — The  attack  usually  occurs  at  night,  and  is 
either  single  or  followed  by  a  number  of  others.  The  child 
wakes  up  suddenly,  making  strenuous  efforts  to  take  breath, 
this  being  attended  by  a  peculiar  inspiratory  stridor.  The 
eyes  are  turned,  the  hands  and  feet  cramped,  and  opistho- 
tonos  may  occur.  This  lasts  a  few  moments,  and  ceases  with 
a  sudden  loud  inspiration,  indicating  the  end  of  the  spasm. 
Occasionally  it  continues  until  asphyxia  takes  place,  the 
child  dying  in  the  midst  of  a  convulsion. 

When,  as  is  most  generally  the  case,  recovery  occurs, 
another  attack  may  take  place  at  any  time,  a  week,  a  month, 


SPASM   OF   THE   LARYNX.  37 i 

or  perhaps  a  year  after  the  first  one,  the  growth  of  a  tooth, 
the  presence  of  food  difficult  to  digest  in  the  stomach, 
unusual  excitement,  etc.,  bringing  on  the  paroxysm.  The 
spasm  is  not  accompanied  by  fever,  pyrexia,  or  coughing, 
and,  as  soon  as  it  is  over,  the  child  recovers  his  usual 
health.  These  peculiarities  serve  to  distinguish  the  affec- 
tion from  others,  especially  croup,  with  which  it  might  be 
confounded. 

Treatment. — The  usual  treatment  employed  for  convulsions 
in  children  can  be  used  here,  dashing  cold  water  in  the  child's 
face,  slapping  his  back,  applying  a  piece  of  ice  suddenly  to 
the  back  of  the  neck,  a  few  whiffs  of  ether  or  chloroform,  am- 
monia or  vinegar.  If  the  mouth  is  opened,  the  tongue  can 
be  drawn  out  so  as  to  raise  the  epiglottis,  which  becomes 
impacted  in  some  cases,  as  shown  by  Cohen;  or,  the  finger 
can  be  passed  deeply  into  the  throat  to  ascertain  whether 
the  epiglottis  is  impacted  or  not,  and,  if  it  is  so,  to  re- 
lease it  by  passing  the  finger  under  it.  Titillating  the  back 
of  the  mouth  with  a  feather,  to  provoke  emesis,  is  another 
method  which  frequently  succeeds.  If  hot  water  be  at  hand, 
a  hot  mustard  foot-bath  or  a  general  warm  bath  is  of  service. 
If  the  attack  persists,  tracheotomy  should  be  resorted  to. 
The  frequent  recurrence  of  spasm  of  the  larynx  in  some 
cases,  renders  prophylactic  measures  necessary.  The  admin- 
istration of  anti-spasmodics  is  indicated  in  conjunction  with 
the  treatment  of  the  direct  cause  of  the  trouble.  Trache- 
otomy as  a  precautionary  measure  is  warranted  in  cases 
where,  in  adults,  there  is  laryngoscopical  evidence  of  a 
paresis  of  the  abductor  muscles. 


CHAPTER  XXVIII. 

DISEASES   OF   THE   LARYNX. — (Continued.) 


TUMOUS. 


TUMORS  of  the  larynx  are  divided  into  three  classes: — 
the  non-malignant^  also  called  benign  tumors,  which  seldom 
return  after  removal ;  the  semi-malignant,  which  do  not  always 
recur  after  extirpation;  and  the  malignant,  whose  tendency 
is  to  return  after  removal,  and  frequently  with  increased 
virulence. 

NON-MALIGNANT   TUMORS. 

Etiology. — The  origin  of  non-malignant  tumors  of  the 
larynx  may  generally  be  traced  to  cold,  or  to  any  cause 
which  maintains  a  prolonged  hypergemia  of  the  mucous  mem- 
brane, such  as  mechanical  irritation  by  dust,  professional 
singing,  chronic  diseases  involving  the  throat,  etc.  Coach- 
men, for  instance,  are  greatly  exposed  to  laryngeal  neoplasms 
on  account  of  the  great  amount  of  exposure  to  which  they 
are  subjected,  while  masons,  stone-cutters,  etc.,  are  also 
prone  to  tumors,  through  the  continued  irritation  brought 
about  by  the  inhalation  of  quarry  dust,  etc.  Diatheses, 
syphilis,  scrofula  or  tuberculosis,  bear  no  influence  upon 
the  causation  of  true  benign  growths ;  in  fact  the  latter  are 
most  frequently  observed  in  persons  of  general  good  health. 
During  an  active  manifestation  of  syphilis  or  tuberculosis  in 
the  larynx,  w^e  may  have,  however,  as  already  pointed  out, 
growths  simulating  papillomata  which  are  sometimes  taken 
for  them ;  but  they  present  a  marked  difference  in  their 
development  and  course,  being  often  of  temporary  duration. 
(378) 


NON-MALIGXANT   TUMORS.  379 

They  give  rise  to  the  same  symptoms,  and  have  frequently 
to  be  removed.  Children  and  adults  are  alike  exposed  to 
laryngeal  non-malignant  tumors,  while  men  are  more  fre- 
quently affected  with  them  than  women,  through  the  greater 
amount  of  exposure  to  which  they  are  subjected. 

Symptoms. — The  symptoms  occasioned  by  the  presence  of 
a  laryngeal  tumor  are  alike  in  the  different  varieties ;  being 
due  to  the  mechanical  obstruction  presented  by  the  growth, 
their  intensity  is  proportionate  with  its  size,  location  and  hard- 
ness. If  the  tumor  is  located  upon  one  of  the  vocal  bauds, 
dysphonia  is  caused  by  the  interference  with  its  proper  vibra- 
tion, while  if  it  is  large  and  located  between  the  bands  at 
the  anterior  commissure,  or  attached  to  the  edge  of  one  of 
them,  it  causes  aphonia,  by  presenting  an  impediment  to 
their  approximation.  If  the  tumor  is  soft,  it  is  liable  to  be 
compressed  between  the  edges  of  the  bands,  and  these  will 
not  approach  each  other  sufficiently  to  permit  perfect  pho- 
nation.  Again,  if  the  tumor  is  not  large  and  situated  above 
the  vocal  bands,  but  slight,  if  any,  subjective  symptoms  will 
occur,  their  incursions  being  free  for  the  purposes  of  pho- 
nation  and  respiration. 

Dyspnoea  can  only  occur  when  the  growth  is  sufficiently 
large  to  diminish  markedly  the  lumen  of  the  glottis.  The 
location  of  the  tumor  plays  another  important  part  in  the 
production  of  this  symptom;  the  nearer  the  neoplasm  to  the 
vocal  bands,  the  earlier  will  it  interfere  with  respiration.  As 
the  growth  of  the  tumor  proceeds,  the  dyspncea  increases, 
and  asphyxia  may  occur  unless  prompt  relief  is  obtained. 

Dysphagia  is  occasioned  when  the  tumor  is  so  situated  as 
to  interfere  with  the  closure  of  the  epiglottis  upon  the 
larynx,  or  when  located  upon  the  external  or  pharyngeal  sur- 
face of  the  latter.  Tumors  of  the  epiglottis,  which  are  not 
infrequently  met  with,  give  rise  to  the  same  mechanical  im- 
pediment, when  sufficiently  large. 


380  DISEASES   OF   THE   LARYNX. 

Cough  is  not  present  as  a  rule,  unless  the  growth  is  suf- 
ficiently soft  to  be  influenced  by  the  air  currents  and  to  titil- 
late the  .surrounding  surfaces.  It  may  also  be  caused  by 
the  interference  presented  by  a  large  growth  to  the  natural 
evacuation  of  the  unusual  amount  of  mucus  formed,  which 
accumulates  in  a  limited  area,  and  causes  irritation.  The 
tumor  sometimes  plays  the  part  of  a  foreign  body,  and  a 
pricking  sensation  is  experienced,  which  causes  a  barking  or 
brazen  cough.  Pain  is  seldom  complained  of. 

Papillomata. — This  class  of  growths  does  not  present  a 
characteristic  appearance  which  enables  a  positive  diagnosis 
to  be  made ;  they,  however,  possess  certain  properties  in 
common,  which  render  an  approximate  recognition  of  their 
nature  possible.  They  are  frequently  sessile  or  broad-based ; 
they  are  frequently  multiple,  and  often  present  small,  round 
projections,  which  cause  them  to  be  termed  raspberry,  mul- 
berry, cauliflower,  etc.,  because  of  their  resemblance  to 
them;  they  are  usually  located  at  the  anterior  portion  of 
the  larynx  and  on  the  vocal  bands,  near  their  anterior  in- 
sertion. 

Their  color  varies  from  a  pale  pink  to  a  dark-red,  while 
their  size  may  be  that  of  a  millet-seed  up  to  that  of  a  walnut. 
Papillomata  are  much  more  frequently  met  with  than  any 
other  form  of  laryngeal  tumor.  As  to  the  likelihood  of  re- 
currence after  extirpation,  the  following  rules,  according  to 
Paul  Bruns  and  Oertel  (quoted  from  Morell  Mackenzie),  who 
divided  papillomata  into  three  classes,  may  furnish  an  ap- 
proximate idea:— 

First  Class.  Light-red,  or  dark  tumors  varying  in  size  from 
a  millet-seed  to  a  bean,  with  uneven  surface  and  broad  base, 
sometimes  solitary,  but  generally  thinly  scattered  and  never 
numerous,  either  do  not  recur  at  all,  or  only  after  some 
months. 


NON-MALIGNANT  TUMOKS.  381 

Second  Class.  Whitish-gray,  exquisitely  papillary,  warty 
or  conical  tumors,  nearly  always  originating  with  a  broad 
base  from  the  vocal  bands  in  adult  patients,  also  recur  very 
slowly,  often  not  till  after  several  years. 

Third  Class.  Large  reddish  tumors,  resembling  a  mulberry 
or  cauliflower.  They  may  be  solitary,  but  are  most  frequently 
multiple,  and  are  commonly  seen  in  children.  These  gener- 
ally recur  after  one  or  two  months. 

Fibromata. — Fibrous  tumors  present  more  definite  physical 
properties.  They  are  generally  smooth  and  single ;  and, 
unlike  the  papillomata,  are  usually  pedunculated.  Their 
color  varies  from  a  bluish-gray  to  a  dark-red,  generally  the 
latter,  and  their  favorite  site  is  also  the  vocal  bands.  They 
may  be  hard  or  soft,  most  frequently  the  former.  They  are 
seldom  larger  than  a  bean,  being  usually  the  size  of  a  pea. 
These  growths  are  not  apt  to  recur. 

The  other  varieties  of  tumors  which  grow  in  the  larynx 
are  very  rarely  met  with.  Among  them  may  be  mentioned 
Angiomata,  which  resemble  a  blackberry  in  shape  and  color. 
Myxomata,  which  are  smooth  or  slightly  irregular,  pinkish 
or  red  and  pedunculated,  generally  located  near  or  in  the 
anterior  commissure,  and  cysts,  which  most  frequently  grow 
on  the  epiglottis,  and  present  a  round,  smooth  surface. 

In  addition  to  the  laryngoscopic  examination,  the  diagnosis 
of  a  laryngeal  growth  may  be  greatly  assisted  by  the  careful 
use  of  the  laryngeal  sound.  The  instrument  shown  in  Fig. 
62  reversed,  can  be  very  conveniently  employed  for  the  pur- 
pose ;  being  malleable,  it  can  be  bent  to  any  shape  and  used 
in  any  situation.  The  irritability  of  the  larynx,  however, 
does  not  allow  of  its  repeated  introduction,  and  under  ordi- 
nary circumstances  the  tumor  is  hardly  touched  but  that  a 
contraction  of  the  larynx  occurs,  and  the  instrument  has  to 
be  withdrawn.  In  a  case  treated  lately  I  applied  a  twenty 


3S2  DISEASES   OF   THE   LARYNX. 

per  cent,  solution  of  cocaine  to  the  entire  laryngeal  cavity, 
and  was  able  for  a  number  of  minutes  to  compress  and 
generally  manipulate  a  large  soft  papilloma  situated  in  the 
anterior  commissure  without  exciting  the  least  reflex  action. 

Treatment. — A  laryngeal  tumor  may  be  destroyed  by  means 
of  caustics,  or  galvano  cautery,  scraped  off  with  the  finger- 
nail, cut  off  with  a  knife,  chain  or  wire  ecraseur,  and  crushed 
or  extirpated  with  forceps. 

Caustics  are  usually  employed  for  small,  soft  growths 
which  cannot  be  grasped  with  forceps,  or  when,  for  one 
reason  or  another,  the  latter  cannot  be  used.  Nitrate  of 
silver  and  chromic  acid  are  the  most  easily  managed  escha- 
rotics,  and  are  devoid  of  danger  if  properly  applied.  The 
introduction  of  cocaine  in  our  list  of  local  anaesthetics  has 
greatly  facilitated  the  treatment  of  endolaryngeal  tumors, 
and  with  its  assistance  an  expert  laryngoscopist  can  not 
only  apply  the  agent  to  the  tumor  at  every  trial,  but  he 
can  also  locate  the  escharotic  to  any  portion  of  that  tumor. 
For  the  application  of  caustics,  a  twenty  per  cent,  solution 
should  also  be  used,  being  applied  a  couple  of  times  at 
three  minutes'  interval. 

The  most  satisfactory  manner  to  apply  nitrate  of  silver  is 
to  fuse  it  at  the  end  of  a  laryngeal  probe,  by  heating  the 
latter  to  the  fire  of  an  alcohol  lamp,  then  applying  the 
heated  tip  against  the  caustic;  enough  will  adhere  for  one 
application.  The  mirror  being  in  position,  the  caustic  is 
applied  to  the  desired  spot,  the  probe  being  manipulated  as 
explained  when  speaking  of  the  laryngeal  forceps  (p.  320). 
In  experienced  hands,  however,  and  when  cocaine  cannot  be 
obtained,  a  covered  probe  is  preferable.  A  very  convenient 
instrument  for  the  application  of  caustics  to  the  larynx  is 
that  shown  in  Fig.  83,  invented  by  Dr.  Alexander  MacCoy, 
of  this  city.  When  the  finger-lever  is  depressed,  the  outer 


NON-MALIGNANT   TUMORS. 


383 


tube  is  drawn  upward,  exposing  the  charged  tip  of  the 
probe,  which  it  covers.  The  outer  tube  being  a  spiral  coil, 
the  probe  inside  can  be  bent  in  any  direction.  Instruments 
of  this  kind,  however,  must  necessarily  present  a  rather 
large  extremity  owing  to  the  outside  tube,  and  the  caustic 
cannot  be  as  nicely  localized. 

The  after-effects  of  these  applications  are  comparatively 
nil;  a  feeling  of  fullness  is  sometimes  experienced,  and  the 
expectoration  is  increased.  At  the  next  visit,  three  or  four 
days  later,  a  small  indentation  will  be  observed  at  the  point 
of  cauterization.  Chromic  acid  is  more  effective,  but  a 
guarded  caustic  applicator  should  always  be  used  for  its 
application,  owing  to  its  greater  destructive  power. 

Fig.  83. 


Dr.  Alexander  MacCoy's  laryngeal  caustic  applicator. 

Soft  tumors,  situated  high  up  in  the  upper  portion  of  the 
larynx,  can  be  scratched  off  with  the  nail  of  the  index  finger, 
as  recommended  by  Cohen ;  this  is  especially  applicable  for 
operations  in  children.  A  small  probe-pointed  or  spear- 
shaped  bistoury,  mounted  upon  a  suitable  handle,  is  used  by 
some  authors  to  shave  the  growth  off,  when  it  is  located  at 
the  margin  of  one  of  the  hands.  The  drawback  to  this 
operation,  however,  is  the  likelihood  of  copious  hemorrhage 
and  the  dropping  of  the  severed  tumor  into  the  trachea. 
Pedunculated  growths  can  be  cut  off  by  means  of  the  cold 
wire  or  galvano-caustic  snare.  These  also  present  the  disad- 


384 


DISEASES   OF   THE  LARYNX. 


vantage,  however,  of  frequently  allowing  the  cut  portion 
to  fall  into  the  windpipe.  When  cocaine  is  used  locally, 
the  contraction  of  the  larynx,  which  detaches  the  tumor 
from  the  loop  (to  which  it  generally  adheres),  does  not  take 
place,  and  it  can  generally  be  brought  up.  The  galvanic 
snare  cauterizes  the  base  of  the  tumor,  while  passing 
through  it. 

Stoerk's  guillotine  and  tube-forceps,  shown  in  Fig.  84,  are 
much  employed  in  Europe  for  the  removal  of  laryngeal 
growths.  The  tube  mounted  upon  the  handle  is  that  of  the 


Fig.  84 


Stoerk's  guillotine  and  tube-forceps  and  attachments. 

guarded  snare,  while  the  disengaged  tube  below,  represents 
the  smaller  guillotine  in  the  act  of  penetrating  a  growth; 
in  succession  then  come  the  larger  guillotine,  a  toothed  claw 
for  tumors,  a  smaller  claw  for  foreign  bodies  and  peduncu- 
lated  growths,  and  a  horizontal  claw  for  neoplasms  located 
in  the  anterior  and  posterior  commissures  and  on  the  edges 
of  the  vocal  bands. 

In  Fig.  85,  the  horizontal  claw,  which  can,  in  this  instru- 
ment, be  rotated  in  any  direction,  is  mounted  upon  the 
handle;  two  guillotines,  a  guarded  snare,  and  a  small  claw 


NON-MALIGNANT  TUMORS. 


385 


for  foreign  bodies  and  pedunculated  growths,  are  then  shown. 
Next  come  galvano-cautery  instruments,  for  the  destruction 
of  small  tumors  or  for  cauterizing  the  seat  of  neoplasms  re- 
moved with  forceps,  guarded  platinum  points  for  the  same 
purposes,  and,  finally,  galvanic  snares  for  the  removal  of 
hard  neoplasms.  In  using  galvano-caustic  instruments,  the 
battery  used  must  be  sufficiently  powerful  to  heat  the  me- 
tallic loop  to  a  cherry-red  at  once,  so  as  to  avoid  prolonged 
radiation. 

Fig.  85. 


Author's  universal  handle  and  laryngeal  attachments. 

The  above  outlined  methods  for  the  removal  of  laryngeal 
neoplasms  are  very  seldom  employed  as  compared  with 
evulsion  by  means  of  the  forceps.  A  great  variety  of  these 
instruments  are  at  our  disposal,  best  known  among  which 
are  Morell  Mackenzie's  (Fig.  86),  Fauvel's  (Fig.  87)  and 
Cusco's  (Fig.  88).  As  can  be  seen  in  the  cut,  Mackenzie's 
forceps  have  a  much  sharper  curve  than  the  other  instru- 
ments, the  object  of  this  being  to  avoid  touching  the 
epiglottis  during  the  operation.  Before  the  introduction  of 

25 


386  DISEASES   OF   THE   LARYNX. 

cocaine,  this  was  an  advantageous  feature  of  the  instrument, 
one  of  the  causes  of  spasmodic  irritation  being  thus  avoided. 
When  the  surface  of  the  epiglottis  can  be  anesthetized,  how- 
ever, an  instrument  with  a  rounded  curve  such  as  that  in 
Fauvel's  or  Cusco's  forceps,  is  preferable;  the  concave  por- 
tion of  the  curve,  by  resting  upon  the  epiglottis,  raises  it 
up  completely,  thus  increasing  the  field  of  vision  to  its 
greatest  extent.  For  large  tumors,  Fauvel's  forceps  are  per- 
haps the  most  satisfactory,  the  perpendicular  position  of  the 

Fig.  86. 


M.  Mackenzie's  laryngeal  forceps. 

claws,  when  opened,  permitting  them  to  seize  with  great 
firmness. 

For  small  growths,  Cusco's  is  an  excellent  instrument,  its 
free  and  delicate  action  and  convenient  shape  enabling  it 
to  be  used  with  very  little  motion  of  the  hand.  Different 
shapes  of  these  several  instruments  must  be  kept  on  hand 
to  suit  the  different  cases. 

The  operation  for  the  evulsion  of  laryngeal  growths 
by  forceps  is  greatly  facilitated  by  the  use  of  cocaine. 
Without  it,  the  larynx  has  to  be  trained,  in  almost  every 
case,  to  the  contact  of  instruments,  by  introducing  the 


NON-MALIGNANT  TUMORS.  387 

forceps  to  be  used  every  day  or  two,  until  it  can  stand 
their  presence  without  reflex  contraction.  With  cocaine, 
however,  such  is  not  the  case,  and  the  operation  can  be 
performed  at  the  first  sitting  if  necessary.  In  a  case  lately 
operated  upon,  the  anaesthesia  produced  by  a  twenty  per 
cent,  solution  was  so  great  that  I  could  touch  any  portion 
of  the  larynx  with  the  greatest  ease,  without  exciting  the 
slightest  irritation.  The  tumor,  a  large  papilloma,  was 
taken  out  in  two  sittings  without  preparatory  training. 
Not  less  than  a  twenty  per  cent,  solution  should  be  used, 


Fig.  87. 


Fauvel's  laryngeal  forceps. 

and  that  should  be  applied  thoroughly  at  least  twice,  at 
three  minutes'  interval.  A  point  of  importance  in  this  con- 
nection is  the  rapidity  with  which  the  anaesthesia  passes 
off;  unlike  in  the  nose,  the  effect  of  cocaine  in  the  larynx 
only  lasts  at  most  ten  minutes,  this  being  probably  due  to 
the  great  amount  of  secretion  which  accompanies  its  appli- 
cation. In  the  case  above  alluded  to,  a  translucent  mucoid 
liquid  could  be  seen  streaming  out  of  the  ventricles,  the 
vocal  bands  being  literally  bathed  with  it.  No  time  should 
be  lost,  therefore,  after  the  application  of  the  anesthetic. 


388  DISEASES   OF   THE   LAKYNX. 

The  tongue  being  held  by  the  patient  and  the  mirror 
placed  in  position,  the  forceps,  previously  warmed,  are  in- 
troduced cautiously  into  the  larynx  and  the  tumor  is 
grasped  between  its  claws,  these  sinking  slightly  into  the 
seat  of  implantation.  Care  must  be  taken  to  hold  the 
growth  firmly;  if  it  is  allowed  to  slip  out,  a  slight  hemor- 
rhage will  occur  which  will  obscure  the  view  and  render 
further  steps  more  difficult.  It  is  then  pulled  off  by  raising 
the  anterior  portion  of  the  instrument,  the  growth  being  gen- 
erally brought  out  entire.  I  have  found  it  advantageous  to 


Fig. 


Cusco's  laryngeal  forceps. 

blacken,  by  exposing  it  to  fire,  about  a  quarter  of  an  inch 
of  the  extremity  of  rny  laryngeal  forceps.  It  can  be  followed 
more  easily  with  the  eye  and  its  location  can  be  ascertained 
with  much  more  accuracy.  Polished  instruments  reflect  the 
surrounding  surfaces  and  appear  of  the  same  color.  Large 
growths  can  be  taken  out  piecemeal  at  different  sittings. 

A  slight  hemorrhage  usually  follows  this  operation,  but  it 
soon  ceases.  The  symptoms  occasioned  by  the  presence  of 
the  tumor  are  at  once  relieved,  except  the  aphonia  or  dys- 
phonia,  which,  however,  generally  disappear  after  a  few  days. 


SEMI-MALIGNANT   TUMOKS.  389 

If  the  vocal  bands  are  damaged  in  the  course  of  the  oper- 
ation, or  involved  in  the  tumor,  hoarseness  is  likely  to  follow. 
Measures  for  the  removal  of  tumors  by  surgical  means  are 
occasionally  followed  by  spasm  of  the  glottis  and  other 
untoward  symptoms  which  may  endanger  the  patient's  life. 
Lennox  Browne,  of  London,  has  had  occasion  to  perform 
tracheotomy  after  an  operation  for  a  benign  growth,  followed 
by  spasm  of  the  glottis.  It  is  probable  that  with  due  care 
such  a  result  cannot  occur. 

The  removal  of  tumors  is  sometimes  performed  from  with- 
out, owing  to  the  impossibility  of  getting  at  them  through 
the  mouth;  the  larynx  may  be  opened  anteriorly  by  an  in- 
cision through  the  angle  of  the  thyroid  cartilage,  an  oper- 
ation first  performed  by  Ephraim  Cutter,  of  New  York.  The 
tumor  being  then  removed,  the  wound  is  closed  up;  it 
generally  heals  spontaneously.  Tracheotomy  is  sometimes 
performed  a  few  days  in  advance,  so  as  to  avoid  the  risk  of 
asphyxia. 

Rossbach,  of  Wurzburg,  introduces  a  thin  knife  antero- 
posteriorly  into  the  median  line  of  the  cavity  of  the  larynx 
from  without,  and  amputates  a  tumor  situated  on  the  edge 
of  the  vocal  band,  watching  the  operation  in  the  laryngeal 
mirror  held  in  the  usual  position. 

SEMI-MALIGNANT   TUMORS. 

Sarcomata  are  the  only  growths  that  can  be  termed  semi- 
malignant,  owing  to  the  possibility  of  cure  which  attends 
their  removal.  They  are  rarely  met  with  in  the  larynx. 
Their  growth  is  generally  very  rapid  and  they  may  attain 
such  size  as  to  render  extirpation  through  the  mouth  im- 
possible. They  may  spring  from  the  cavity  of  the  larynx, 
usually  from  the  upper  part,  or  from  its  external  wall.  Their 
appearance  varies  greatly,  resembling  in  some  cases  a  papil- 


390  DISEASES    OF   THE   LARYNX. 

loma,  and  in  others  a  fibroma.  In  a  case  seen  by  me,  the 
growth  was  rounded,  dark  and  sessile,  and  about  the  size  of 
a  large  pea.  The  surface,  instead  of  being  smooth,  is  often 
quite  irregular.  This  irregularity  of  appearance,  however, 
renders  a  differential  diagnosis  with  other  tumors  a  rather 
difficult  matter,  which  the  microscope  alone  can  render 
positive. 

The  symptoms  of  this  form  of  tumor  vary  with  the  location 
of  the  growth.  In  the  larynx,  its  pressure  presents  a  me- 
chanical obstruction  to  respiration  and  phonation,  asphyxia 
sometimes  resulting ;  when  upon  its  external  surface,  the 
growth  offers  an  impediment  to  deglutition. 

A  small  sarcoma  can  be  removed  by  any  of  the  methods 
described  for  non-malignant  tumors.  When  too  large  to  be 
removed  through  the  mouth,  thyrotomy  or  extirpation  of 
the  entire  larynx  may  become  necessary,  according  to  the 
location  and  size  of  the  growth. 

MALIGNANT   TUMOES   OF   THE   LAKYNX. 

The  malignant  growths  found  in  the  larynx  comprise 
principally  the  three  varieties  of  cancer — epithelioma,  encepha- 
loid  and  scirrhus — the  first  being  by  far  the  most  fre- 
quently met  with.  They  may  occur  primarily,  or  as  a  sec- 
ondary manifestation  of  a  cancer  in  other  organs,  or 
through  extension  from  neighboring  parts.  A  malignant 
growth  seldom  presents  itself  before  the  fortieth  year,  and 
is  much  more  frequently  met  with  in  males  than  females. 
It  can  frequently  be  traced  to  heredity.  In  persons  in  whom 
a  hereditary  proclivity  to  carcinoma  exists,  it  is  probable 
that  undue  exposure  of  the  throat  to  cold,  continued  irrita- 
tion by  excessive  smoking,  etc.,  may,  by  maintaining  a  local 
congestion,  encourage  the  development  of  a  growth  which 
might  not  otherwise  have  shown  itself. 


MALIGNANT  TUMORS   OF  THE  LARYNX.  391 

Symptoms. — The  early  symptoms  are  generally  not  marked. 
Hoarseness  is  the  first  source  of  complaint,  presenting 
itself  sometimes  long  before  the  active  symptoms.  As  the 
case  progresses,  however,  they  become  more  and  more  dis- 
tinct, until  much  suffering  is  incurred,  its  nature  depending 
upon  the  location  of  the  cancer.  If  located  high  up,  marked 
odynphagia  may  exist  in  conjunction  with  the  pain  of  the 
growth  proper,  which  is  sharp  and  lancinating.  If  the 
cavity  of  the  larynx  is  the  seat  of  the  tumor,  phonation  is 
more  and  more  difficult  until  complete  aphonia  exists,  and 
dyspnoea  becomes  a  prominent  symptom  early  in  the  history 
of  the  case.  When  ulceration  begins,  the  suffering  -is  fre- 
quently increased  by  violent  shooting  pains,  extending  to  the 
ears,  orbit  and  forehead.  The  breath  at  this  time  becomes 
very  fetid,  and  repeated  hemorrhages  may  occur ;  the  latter, 
in  conjunction  with  the  small  quantity  of  food  taken, 
weakens  the  patient  greatly  and  advances  the  fatal  issue. 
The  cachectic  appearance  is  only  present  in  cases  of  long 
duration. 

The  laryngoscopic  appearances  vary  according  to  the 
variety  of  cancer  present  and,  of  course,  to  the  stage  of 
the  disease.  In  the  great  majority  of  cases,  the  seat  of  the 
cancer  is  on  one  of  the  ventricular  bands.  In  the  early 
stages,  the  affected  band  is  irregularly  thickened,  nodules 
appearing  here  and  there  which  present  either  a  grayish- 
red  or  a  dark-red  color.  In  epithelioma,  the  grayish-red 
color  predominates,  and,  as  shown  by  Fauvel,  as  soon  as 
ulceration  begins,  vegetations  show  themselves  around  the 
edge  of  the  ulcer,  and,  breaking  down  in  turn,  rapidly  in- 
crease the  loss  of  substance;  in  encephaloid  cancer,  the 
vegetations  spring  from  the  surface  of  the  ulcer  and  do  not 
involve  the  surrounding  tissues,  the  loss  of  substance  taking 
place  by  gradual  extension  of  the  primary  ulcer.  Scirrhus 


392  DISEASES   OF   THE   LAKYNX. 

cancers  resemble  non-malignant  growths  at  the  beginning, 
especially  fibromata,  being  also  hard  to  the  touch  of  the 
probe.  It  soon  becomes  inflamed  and  opens,  a  deep,  exca- 
vated ulcer  being  formed,  which  gradually  increases  at  the 
expense  of  the  surrounding  parts.  Death  takes  place  earlier 
in  the  first  variety  than  in  the  others,  a  year  frequently  being 
the  extent  of  life  after  the  symptoms  have  become  recog- 
nizable. 

Treatment — The  constant  recurrence  characterizing  ma- 
lignant growths  precludes  the  employment  of  curative  meas- 
ures other  than  complete  evulsion,  this  involving,  to  be  done 
thoroughly,  the  entire  larynx  in  many  cases.  Extirpation  of 
the  larynx  is,  in  itself,  so  rarely  successful  as  to  scarcely  be 
warrantable.  Tracheotomy,  performed  early,  retards  the 
fatal  issue  on  an  average  about  nine  months,  according  to 
Fauvel,  not  only  through  the  fact  that  free  respiration  is 
secured,  but  also  on  account  of  the  rest  procured  for  the 
larynx. 

Palliative  measures,  properly  conducted,  are  very  valuable 
in  insuring,  for  the  patient,  comparative  comfort.  A  borax 
spray,  to  render  the  discharges  liquid  and  thus  facilitate 
their  expectoration,  is  generally  grateful  to  the  patient, 
avoiding  for  him  the  painful  scraping  and  hawking  neces- 
sary to  accomplish  the  same  object.  A  four  per  cent,  solu- 
tion of  cocaine,  increased  in  strength  as  the  parts  become 
accustomed  to  its  effects,  or  lozenges  containing  from  gr.  1  to 
%  of  the  drug,  may  be  used  with  great  benefit  to  subdue  the 
pain  and  facilitate  deglutition.  Morphia  gr.  £  to  i,  gently 
insufflated  over  the  ulcerated  parts,  is  also  very  effective. 
When  deglutition  becomes  very  painful,  the  alimentation 
bottle  of  Bryson  Delavan  (Fig.  81)  is  admirably  adapted  to 
nourish,  the  patient  and  thus  counteract  one  of  the  frequent 
causes  of  death  in  cancer,  inanition. 


FOREIGN    BODIES   IN    THE   LARYNX.  393 

FOREIGN   BODIES   IN   THE   LARYNX. 

A  list  of  the  different  kinds  of  foreign  bodies  that  have 
become  impacted  in  the  larynx  would  include  almost  every 
article  capable  of  being  introduced  into  the  mouth.  Those 
which  most  frequently  become  lodged  there,  however,  are 
principally  articles  of  diet,  bones,  bread-crusts,  fish-bones,  etc., 
which  are  drawn  into  the  air-passages  during  a  fit  of  laughter, 
just  as  the  act  of  deglutition  is  being  performed.  Their 
penetration  into  the  air-tract  depends  greatly  upon  their  size, 
small  objects  being  frequently  drawn  down  into  the  trachea, 
while  large  objects  remain  in  the  upper  part  of  the  cavity. 
The  symptoms  of  a  foreign  body  may  be  due  to  impaction  of 
a  portion  of  the  epiglottis  in  the  larynx  proper.  Teeth, 
natural  or  artificial,  pieces  of  necrosed  bone  or  cartilage, 
coming  from  the  naso-pharynx,  or  the  larynx  itself,  repre- 
sent another  class  of  foreign  bodies  which  occasionally  cause 
occlusion. 

Symptoms. — The  sudden  impaction  of  a  foreign  body  in 
the  larynx  provokes  immediate  and  violent  coughing — a 
reflex  effort  to  dislodge  the  offending  object,  Sometimes 
this  succeeds,  the  foreign  body  is  coughed  up  and  out,  and 
the  patient  recovers  at  once,  although  his  throat  may  remain 
painful  for  several  days.  When  the  foreign  body  is  large 
enough  to  fill  the  laryngeal  cavity  sufficiently  to  occlude  it, 
and  the  first  expulsory  effort  does  not  succeed,  the  patient, 
having  comparatively  emptied  his  lungs  of  air,  finds  it  im- 
possible to  inhale,  each  effort  causing  the  offending  object  to 
impact  itself  more  tightly  in  the  glottis.  As  graphically 
described  by  the  late  Professor  Gross  (quoted  by  Cohen), 
"  the  patient  is  seized  with  a  feeling  of  annihilation  ;  he  gasps 
for  breath,  looks  wildly  around  him,  coughs  violently,  and 
almost  loses  his  consciousness.  His  countenance  immediately 


394  DISEASES   OF  THE  LAKYNX. 

t 

becomes  livid,  his  eyes  protrude  from  their  sockets,  the  body 
is  contorted  in  every  possible  manner,  and  froth,  and  even 

sometimes  blood,  issues  from  the  mouth  and  nose The 

heart's  action  is  greatly  disturbed,  and  not  infrequently  the 
individual  falls  down  in  a  state  of  insensibility,  unable  to 
execute  a  single  voluntary  function."  When  the  entrance  of 
air  is  completely  prevented,  the  sufferer  may  die  in  a  few 
moments,  and  before  any  assistance  can  be  lent  him.  Pieces 
of  meat  are  the  most  frequent  causes  of  such  an  accident, 
their  consistence  permitting  them  to  adjust  themselves  to 
the  sinuosities  of  the  laryngeal  aperture.  In  the  great  ma- 
jority of  cases,  however,  the  object  is  of  such  a  shape  and 
form  that  sufficient  air  is  permitted  to  enter  the  lungs  to 
keep  the  patient  alive.  In  this  case,  the  first  paroxysm, 
although  severe,  soon  subsides ;  violent  paroxysms  of  cough- 
ing follow,  and,  after  a  few  minutes,  comparative  comfort  is 
enjoyed  until  another  coughing  spell  brings  on  dyspnoea  and 
a  renewal  of  the  first  symptoms.  After  a  time,  the  larynx 
seems  to  become  accustomed  to  its  new  occupant,  and  a 
small  object  may  even  be  forgotten  and  ejected  in  a  fit  of 
sneezing  or  coughing  long  after.  In  many  cases,  however, 
such  is  not  the  case,  and  organic  lesions  may  be  caused  which 
may  endanger  the  patient's  life.  The  inflammation  occa- 
sionally extends  to  the  lungs,  and  a  fatal  result  may  be 
caused  by  pneumonia.  Again,  notwithstanding  the  sponta- 
neous expulsion  of  a  foreign  body,  secondary  inflammation 
may  follow  and  endanger  the  patient  by  oedema  of  the 
larynx. 

Treatment. — The  simplest  means  are  sometimes  sufficient 
to  dislodge  an  impacted  body.  A  violent  slap  on  the  back, 
just  as  an  expulsory  effort  is  being  performed  by  the  patient, 
often  succeeds.  In  a  case  under  my  care,  a  large  piece  of 
bone,  which  occluded  the  cavity  of  the  larynx  almost  en- 


FOREIGN  BODIES  IN  THE  LARYNX.  395 

tirely,  judging  by  the  amount  of  dyspnoea  present,  was  thus 
dislodged.  At  times,  the  object  remains  over  the  aperture 
and  can  easily  be  removed  with  the  finger.  As  we  have 
seen  under  the  heading  of  foreign  bodies  in  the  pharynx, 
the  epiglottis  may  be  held  down  by  the  impacted  body  so 
as  to  completely  close  the  laryngeal  aperture ;  the  linger  can 
also  be  used  in  this  case. 

When  the  foreign  body  presents  a  certain  degree  of  weight, 
such  as  a  piece  of  coin,  a  bullet,  etc.,  an  effort  may  be 
made  to  cause  its  fall  from  the  larynx  by  inverting  the 
body,  the  patient  standing  on  his  hands  while  his  feet  are 
held  up;  or  he  may  be  placed,  face  downward,  on  a  table, 
one  end  of  which  is  then  raised  as  high  as  possible. 

Pins  and  needles,  tacks,  bones,  i.e.,  objects  having  a  tend- 
ency to  penetrate  into  the  tissues  when  efforts  at  expul- 
sion are  made,  which  causes  them  to  increase  their  hold,  can 
be  withdrawn  by  means  of  forceps  with  the  assistance  of 
the  laryngeal  mirror.  Before  cocaine  was  introduced,  this 
was  an  exceedingly  difficult  procedure.  The  larynx,  through 
the  pressure  of  the  foreign  body,  becomes  much  more  sensi- 
tive than  usual,  and  the  mirror  can  hardly  be  borne,  let 
alone  the  forceps.  In  the  midst  of  the  retching  and  gagging, 
which  occurred  in  most  cases,  the  forceps  had  to  be  intro- 
duced, and  advantage  taken  of  an  effort  at  inspiration  to 
seize  the  object  and  draw  it  out.  "With  cocaine,  however, 
the  operation  is  greatly  simplified;  a  twenty  per  cent,  solu- 
tion applied  generously  to  the  laryngeal  membrane  and  all 
the  parts  around  the  larynx,  including  the  epiglottis  and 
the  base  of  the  tongue,  so  anesthetizes  the  throat  as  to 
render  the  extraction  of  the  foreign  body  a  comparatively 
easy  task.  Seller's  tube  forceps  (Fig.  69),  is  perhaps  the 
most  convenient  instrument  to  grasp  small  objects,  while 
FauvePs  (Fig.  87)  may  be  used  for  large  ones. 


0(JO  DISEASES    OF    THE   LAKYNX. 

When  the  foreign  body  cannot  be  reached  and  suffocation 
is  threatened,  tracheotomy  is  the  only  resort,  and  should  be 
performed.  If  the  necessary  instruments  are  not  at  hand, 
the  trachea  may  be  opened  with  a  penknife  and  the  wound 
kept  patulous  with  bent  hairpins,  secured  by  means  of  a 
piece  of  tape  passed  around  the  patient's  neck;  or,  the 
thyro-cricoid  membrane  may  be  divided,  thus  furnishing 
a  sufficient  opening  for  the  admission  of  air  until  more  de- 
cided measures  can  be  adopted.  Before  doing  this,  however, 
it  is  advisable  to  ascertain  as  nearly  as  possible  the  location 
of  the  foreign  body,  to  avoid  making  an  unnecessary  open- 
ing in  case  it  should  have  fallen  into  the  trachea.  The 
location  of  the  foreign  body  may  be  ascertained  by  auscul- 
tation, a  whistling  noise  being  audible  at  the  point  of  im- 
paction ;  a  stethoscope  may  be  used  for  the  neck. 

Tracheotomy  is  occasionally  performed  to  enable  a  foreign 
body  impacted  in  the  trachea  to  be  coughed  out.  In  this 
case,  the  opening  made  in  the  windpipe  should  be  longer  than 
for  the  introduction  of  the  canula,  one  inch  and  a  quarter 
for  an  adult  and  about  one  inch  for  a  child  being  the  extent 
recommended  by  Professor  Gross.  The  spontaneous  extru- 
sion of  the  foreign  body  is  thus  greatly  facilitated. 

Cocaine,  it  seems  to  me,  could  be  used  to  great  advantage 
for  the  mechanical  removal  of  foreign  bodies  located  in  the 
trachea,  and  especially  in  either  bronchi,  through  a  trachea! 
opening.  For  the  removal  of  an  object  located  above  the 
wound,  thorough  anaesthesia  of  the  larynx  from  above,  and 
also  from  below,  by  means  of  a  small  atomizer  with  a 
curved  tip,  using  a  twenty  per  cent,  solution,  would  enable 
a  small  mirror  to  be  introduced  into  the  trachea,  through 
the  wound,  without  provoking  cough.  A  probe,  curved 
upward,  could  then  be  passed  in,  and  the  foreign  body 
pushed  up  into  and  out  of  the  larynx.  The  operation  can 


FOKEIGN   BODIES   IN   THE   LARYNX.  397 

thus  be  conducted  in  the  safest  possible  manner,  and  be 
accomplished  much  more  rapidly.  A  foreign  body  impacted 
in  one  of  the  bronchi,  will  readily  be  seen  by  introducing 
the  mirror  with  its  face  downward;  the  anaesthetic  having 
been  carefully  applied,  its  exact  location,  shape  and  sur- 
roundings can  be  ascertained,  and  a  suitable  forceps  em- 
ployed for  its  extraction. 


CHAPTER   XXTX. 

ARTIFICIAL   OPENINGS   INTO   THE   LARYNX   AND   TRACHEA. 

ARTIFICIAL  openings  into  the  larynx  and  trachea  are  most 
frequently  made  to  secure  tHe  access  of  air  to  the  lungs, 
when,  through  some  obstruction  in  the  larynx  or  trachea, 
respiration  cannot  take  place  through  the  natural  channels. 
They  are  also  occasionally  made  for  the  purpose  of  removing 
neoplasms  and  foreign  bodies  from  the  larynx  and  trachea, 
when  withdrawal  through  the  mouth  is  impracticable. 

The  different  operations  that  can  be  performed  are  : — laryn- 
gotomy,  tliyrotomy,  laryngo-traclicotomy  and  tracheotomy. 

LARYNGOTOMY. 

Laryngotomy  is  the  simplest  of  the  operations  for  the 
artificial  admission  of  air  into  the  respiratory  tract.  It  is 
principally  useful  when  the  obstruction  to  normal  respiration 
is  to  be  of  short  duration,  such  as  the  presence  of  a  foreign 
body,  oedema  of  the  glottis,  and  fracture  of  the  larynx.  It 
consists  in  making  an  opening  through  the  crico-thyroid 
membrane.  The  patient  being  placed  on  a  table,  his 
shoulders  are  raised  so  as  to  cause  extension  of  the  neck. 
A  vertical  incision  being  made  through  the  integument,  in 
the  median  line,  beginning  at  a  point  about  representing 
the  middle  of  the  thyroid  cartilage,  and  extending  down- 
ward to  about  the  first  tracheal  ring,  the  handle  of  the 
scalpel  is  used  to  uncover  the  crico-thyroid  membrane, 
over  which  will  be  seen  coursing  the  crico-thyroid  artery 
and  vein.  These  being  pushed  aside,  a  transverse  incision 
is  made  through  the  membrane,  taking  care  to  penetrate 
(398) 


THYROTOMY.  399 

the  mucous  membrane  of  the  trachea.  A  canula  (that  gen- 
erally used  being  flattened  from  above  downward,  instead 
of  round)  is  then  passed  into  the  larynx,  and  secured  by 
means  of  tapes  tied  around  the  neck.  The  canula,  in  this 
operation,  should  not  be  left  in  situ  for  any  length  of  time, 
owing  to  the  danger  of  necrosis  of  the  thyroid  or  cricoid 
cartilages.  The  after-treatment  is  the  same  as  that  for 
tracheotomy,  and  will  be  described  under  that  heading. 
When  the  canula  is  withdrawn,  the  parts  usually  heal 
without  trouble.  The  operation  is  occasionally  performed 
for  the  extraction  of  foreign  bodies  or  neoplasms,  which 
cannot  be  withdrawn  by  the  ordinary  methods. 

THYROTOMY. 

This  operation  consists  in  separating  the  two  wings  of  the 
thyroid  cartilage  anteriorly,  thus  exposing  advantageously 
the  cavity  of  the  larynx  for  the  removal  of  tumors  or 
foreign  bodies  which  have  resisted  the  ordinary  procedures. 

The  thyroid  prominence  being  rendered  as  marked  as  pos- 
sible by  raising  the  patient's  shoulders  and  tilting  his  head 
backward,  a  perpendicular  incision,  beginning  at  the  thyro- 
hyoid  space  and  ending  at  the  cricoid  cartilage,  is  made  ex- 
actly in  the  median  line,  and  the  underlying  fasciae  are 
divided  carefully,  "using  the  grooved  director.  As  soon  as 
this  is  done,  the  thyroid  prominence  bulges  out  of  the 
wound,  and  can  be  opened  by  passing  a  sharp  and  strong 
bistoury  under  its  lower  edge,  cutting  upward.  When  the 
cartilage  is  ossified,  a  pair  of  bone  forceps  or  a  fine  saw, 
such  as  that  shown  in  Fig.  46,  has  to  be  used.  A  pair  of 
hooks  or  retractors  are  then  adjusted  to  the  sides  of  the 
opening,  and  held  in  position  by  means  of  tapes  passed 
around  the  neck.  The  operation  is  a  comparatively  bloodless 
one,  and  exposes,  in  a  very  satisfactory  manner,  the  interior 


400      ARTIFICIAL   OPENINGS   INTO    THE   LARYNX    AND    TRACHEA. 

of  the  larynx.  When  the  foreign  body  or  the  tumor  has 
been  removed,  careful  apposition  of  the  cut  surfaces  will 
generally  bo  followed  by  union  by  first  intention.  The  voice 
is  usually  affected  for  a  certain  period  after,  but  it  almost 
always  returns  to  its  normal  condition. 

LARYNGO-TRACHEOTOMY. 

When  after  either  of  the  two  operations  just  described  the 
opening  is  not  sufficiently  large  for  the  purposes  required, 
laryngo-tracheotomy  becomes  necessary.  It  consists  of  an 
extension  of  the  incision  made,  either  in  laryngotomy  or 
thyrotomy,  to  the  cricoid  cartilage,  and  dividing  the  latter 
and  the  first  ring  of  the  trachea.  Care  should  be  taken  not 
to  cut  below  this  limit,  lest  the  isthmus  of  the  thyroid 
gland,  immediately  below,  be  divided,  and  give  rise  to  pro- 
fuse hemorrhage.  An  extended  view  of  the  larynx  and 
trachea  is  thus  obtained.  The  cricoid  cartilage  is  sometimes 
penetrated  with  difficulty,  owing  to  ossification,  rendering 
the  use  of  a  saw  or  bone  forceps  necessary. 

TRACHEOTOMY. 

Tracheotomy,  or  opening  of  the  trachea,  is  resorted  to 
much  more  frequently  than  any  of  the  other  operations.  It  is 
performed  in  the  following  manner :  The  patient  being  anaes- 
thetized, he  is  placed  on  a  table,  and  the  shoulders  are  raised 
to  cause  extension  of  the  neck.  A  line  representing  the 
location  and  length  of  the  incision,  extending  from  the 
cricoid  cartilage  to  within  a  third  of  an  inch  from  the  top  of 
the  sternum,  is  traced  with  ink,  so  as  to  avoid  losing  the 
middle  line.  The  skin  is  then  raised  by  pinching  it  up  in  a 
transverse  fold  with  its  apex  at  the  middle  of  the  ink  line, 
and  the  bistoury  is  passed  through  the  fold,  the  sharp  edge 


TRACHEOTOMY.  401 

being  upward.  The  transverse  fascia  will  then  come  into 
view;  this  being  raised  in  the  same  manner  as  the  skin,  is 
also  divided  in  the  same  way;  but  a  small  cut  should  be 
made,  however,  sufficiently  large  for  the  introduction  of 
the  point  of  a  grooved  director.  With  this  instrument  the 
fascia  is  raised  at  one  end  of  the  incision,  and  if  no  under- 
lying vessel  is  seen  between  the  director  and  the  fascia,  the 
blunt  side  of  the  bistoury  is  placed  in  the  groove,  and  its 
sharp  edge,  turned  upward,  is  pushed  through  the  fold  of 
fascia.  This  is  repeated  for  the  lower  end  of  the  cut.  The 
deep  fascia,  which  comes  next  into  view,  and  unites  the  two 
pairs  of  muscles — the  sterno-hyoid  and  sterno-thyroid — is 
treated  in  the  same  way.  Care  should  be  taken  in  dividing 
the  folds  of  the  fascia,  to  make  the  incision  in  them  as  long 
as  that  of  the  skin,  to  avoid  a  funnel-shaped  wound  by  the 
time  the  trachea  is  reached.  A  layer  of  areolar  tissue  is 
then  met  with,  containing  some  fat  and  engorged  veins.  If 
possible,  the  latter  should  be  pushed  aside  gently  with  the 
convex  surface  of  the  grooved  director,  or  with  the  handle  of 
the  knife,  and  if  this  cannot  be  done,  two  ligatures  are  passed 
around  the  vessels  some  distance  apart,  and  the  latter  are  then 
divided.  By  this  time  the  sides  of  the  wound  tend  to  come 
together  and  interfere  with  further  steps;  and  if  assistants 
are  at  hand,  hooks  must  be  used  to  keep  the  wound  open. 
In  a  case  of  emergency,  with  no  one  to  assist  me,  Bosworth's 
nostril  dilator  (Fig.  8)  served  the  purpose  admirably,  its 
blades  being  bent  outward  somewhat  so  as  to  prevent  their 
slipping  out. 

At  this  stage  of  the  operation,  the  depth  of  the  wound 
exceeds  greatly  the  expectation  of  the  young  operator,  and 
he  is  apt  to  believe  that  the  trachea  has  been  "missed," 
considering  its  apparent  proximity  to  the  skin  before  the 
operation  was  begun.  His  fears  will  be  quieted,  however, 

26 


402      ARTIFICIAL   OPENINGS   INTO   THE   LARYNX   AND   TRACHEA. 

when,  after  carefully  separating  the  layer  of  cellulo-adipose 
tissue  in  the  median  line  with  the  grooved  director,  watch- 
ing for  vessels,  the  denuded  trachea  will  appear.  At  the 
upper  part  of  the  wound  in  this  location,  the  isthmus  of  the 
thyroid  gland  will  generally  be  found;  it  should  be  pushed 
upward  and  out  of  the  line  of  the  cut,  if  possible ;  if  not,  it 
should  be  divided  between  two  ligatures. 

An  important  point,  is  to  control  any  bleeding  arteriole 
or  vein  that  may  cause  the  bottom  of  the  wound  to  quickly 
become  hidden  in  blood.  This  may  be  done  by  means  of 
small  sponges,  and  by  ligating  any  vessel  of  importance,  the 
ligatures  being  cut  short.  The  wound  being  comparatively 

Fig.  89. 


Trousseau's  dilator. 


dry,  the  next  step  is  to  open  the  trachea.  To  prevent  any 
deflection  of  the  latter  it  must  be  held  firmly  by  means  of 
a  sharp  .tenaculum  stuck  through  its  wall  at  the  upper  com- 
missure of  the  wound,  with  the  handle  towards  the  face  of 
patient.  Raising  the  trachea  slightly  from  its  bed  and  hold- 
ing it  firmly,  the  point  of  a  small  but  strong  bistoury  is 
pushed  through  its  wall,  beginning  at  the  lower  part  of  the 
exposed  portion,  the  back  of  the  instrument  being  turned 
towards  the  sternum.  Cutting  upward  carefully,  avoiding 
long  sweeps  so  as  not  to  wound  the  opposite  suface  of  the 
trachea,  three  rings  are  divided,  making,  in  an  adult,  an 
incision  about  three-quarters  of  an  inch  in  length.  The 
curved  tips  of  an  instrument  such  as  that  shown  in  Fig.  89, 


TKACHEOTOMY.  403 

are  then  introduced  into  the  tracheal  opening,  and  the  rings 
being  approximated,  its  edges  are  separated. 

The  moment  the  trachea  is  opened,  a  quantity  of  mucus 
tinged  with  blood  is  generally  coughed  out,  and  the  lungs 
seem  to  empty  themselves  of  all  the  air  in  them ;  the 
patient  then  ceases  to  breathe,  and  a  period  is  passed 
during  which  respiration  seems  completely  suspended,  a 
source  of  great  anxiety  to  an  operator  of  limited  experience. 
At  last,  a  long,  deep  breath  is  taken,  and  from  that  on  respi- 
ration is  normal.  The  canula  can  either  be  introduced  as 
soon  as  the  trachea  is  opened,  or  after  the  respiration  has 
been  re-established.  I  prefer  the  latter  procedure,  the  larger 
opening  serving  better  for  the  evacuation  of  what  mucus, 
blood,  etc.,  may  be  present  in  the  trachea;  than  the  aperture 
of  the  canula.  After  two  or  three  inspirations  have  been 
taken,  therefore,  the  instrument  is  gently  but  quickly  in- 
troduced, the  tracheal  retractors  being  disengaged  at  the 
same  time.  An  exception  to  this  practice  should  always  be 
made,  however,  when  there  is  hemorrhage  of  the  tissues, 
and  when  time  cannot  be  taken  to  arrest  it.  In  this  case, 
two  small  sponges  are  pressed  tightly  on  the  bleeding  tissues, 
one  on  each  side  of  the  trachea,  and,  the  latter  being  suddenly 
opened,  the  canula  is  immediately  introduced,  the  sponges 
being  taken  off  at  the  same  time.  The  flow  of  blood  ceases 
almost  immediately  upon  the  restoration  of  the  normal 
breathing;  for  prudence's  sake,  however,  the  patient  should 
be  raised  and  leaned  forward,  so  as  to  cause  what  blood 
might  ooze  from  the  wound  to  flow  externally,  instead  of  in 
the  trachea.  When  the  operation  has  been  satisfactorily  per- 
formed, the  external  wound  above  and  below  the  tube  is 
closed  by  adhesive  strips,  taking  care  to  approximate  and 
adjust  the  edges  accurately.  The  lower  end  of  the  wound 
should  remain  open  for  drainage. 


404         ARTIFICIAL   OPENINGS    INTO    THE   LAKYNX   AND   TRACHEA. 

The  choice  of  a  canula  is  an  important  matter.  Of  the 
large  number  at  our  disposal,  that  of  Trousseau,  improved 
by  Roger,  who  made  the  neck  plate  movable  around  the 
tube  so  as  to  give  the  latter  free  motion,  and  further  im- 
proved by  Ober,  who  first  proposed  the  use  of  an  inner  tube, 
which  can  be  taken  out  at  will  for  cleansing,  thus  avoiding 
the  necessity  of  withdrawing  the  external  tube,  is  probably 
the  best.  As  generally  sold,  the  outer  tube  is  furnished  with 
an  oval  opening  or  fenestra  on  the  upper  side  of  the  curved 
portion  to  enable  the  patient  to  breathe  through  the  natural 
passages,  or  to  talk  by  placing  his  finger  on  the  external 


Fig.  90. 


Trousseau's  tracheotomy  tube,  improved,  showing  the  method  employed  to  attach  the  neck-tape. 

opening  of  the  canula.  This  is  not  only  an  unnecessary 
addition  to  the  instrument,  but  a  pernicious  one.  The  space 
around  the  part  of  the  canula  inside  the  trachea  is  suf- 
ficiently large  to  enable  the  patient  to  breathe  and  speak; 
as  to  the  fenestra,  it  is  liable  to  irritate  the  mucous  membrane 
of  the  posterior  wall  of  the  trachea,  and  cause  ulceration. 
The  instrument  should  either  be  of  silver  or  of  aluminium, 
the  latter  metal  presenting  the  advantage  of  light  weight. 
The  hard-rubber  tracheotomy-tubes  which  are  generally 
sold  are  undesirable  owing  to  their  thickness,  and  the  diffi- 
culty of  keeping  them  clean.  As  to  the  sizes  that  should 


TEACHEOTOMY. 


405 


be  employed  for  the  different  ages,  the  scale  shown  in  Fig. 
91  may  be  found  useful.  It  represents  the  size  which  the 
orifice  of  the  internal  tube  should  present,  to  supply  the 
lungs  with  a  sufficient  amount  of  air.  It  is  based  upon 
experiments  conducted  by  means  of  tubes  held  between  the 
lips,  the  nose  being  closed  with  the  fingers.  A  smaller 
diameter  than  that  represented  in  the  cut  as  being  required 
by  a  given  case,  would,  after  a  few  moments,  cause  an  un- 
comfortable "need  of  more  air."  According  to  the  scale, 
the  measurements  of  which  are  given  in  millimetres,  the 
canula  shown  in  Fig.  92  would  be  adaptable  for  a  child 
about  two  or  three  years  of  age.  The  oval  shape  is  selected, 
because  it  enables  the  air  to  pass  freely  on  each  side  of 

Fig.  91. 


|Y       2Y     4Y       6Y        8Y        10  Y        I2Y       14-Y       |6Y         I8Y         20  Y 


Author's  scale  for  tracheotomy  tubes. 

the  tube  if  the  patient  wishes  to  use  his  voice,  and  because 
it  exerts  less  pressure  upon  the  sides  of  the  tracheal  wound. 
The  tube  is  sufficiently  small,  as  compared  with  the  cavity 
of  the  trachea,  to  enable  it  to  have  free  motion  during 
deglutition. 

After-treatment. — The  success  of  the  operation  depends  as 
much  upon  the  judicious  care  bestowed  upon  the  patient, 
and  the  proper  attention  to  details,  as  it  does  upon  the  skill 
of  the  operator.  During  the  operation,  and  as  long  as  the 
patient  is  confined  to  his  room,  generally  about  a  week,  the 
atmosphere  should  be  kept  at  a  temperature  of  not  less  than 
80°  Fahr.,  and  maintained  in  a  moist  state  by  means  of 
steam,  obtained  by  boiling  water  in  the  apartment.  In  short, 
the  object  should  be  to  furnish  the  lungs  with  air  possessing 


406         ARTIFICIAL    OPENINGS    INTO    THE   LARYNX   AND    TRACHEA. 

as  nearly  as  possible  the  properties  it  would  possess  if  it 
were  inhaled  through  the  nose.  To  further  attain  this  object, 
the  foreign  particles  floating  in  the  atmosphere  can  be  ar- 
rested at  the  mouth  of  the  canula  by  straddling  a  piece  of 
thin  muslin  over  it;  care  should  be  taken,  however,  not  to 
attach  it  so  as  to  interfere  with  the  free  discharge  of  mucus. 
The  best  means  is  to  tie  a  thin  muslin  handkerchief  around  the 
neck,  above  the  canula,  letting  it  overhang  its  orifice.  This 
not  only  prevents  the  ingress  of  dust  during  inspiration,  but 


Fig.  92. 


Tracheotomy  tube  with  inner  canula  drawn  out. 

also  serves  to  prevent  the  regurgitation  of  mucus,  which  often 
takes  place  without  such  a  contrivance,  when  a  coughing 
spell  forces  the  discharges  up  to  the  mouth  of  the  tube. 

An  important  point  is  to  keep  the  canula  as  free  as  pos- 
sible from  the  copious  discharges  which  are  formed  for  a 
couple  of  days  after  the  operation.  An  intelligent  attendant 
should  be  carefully  instructed  to  withdraw  the  inner  canula 
every  two  hours,  to  cleanse  it  carefully  with  hot  water,  then 
to  re-introduce  it  into  the  outer  tube  after  having  effectively 
freed  the  cavity  of  the  latter  of  any  mucus  that  might  have 


TRACHEOTOMY.  407 

accumulated  there.  This  may  be  done  by  means  of  a  feather, 
a  piece  of  sponge,  or  absorbent  cotton  securely  and  tightly 
fastened  to  a  suitably  bent  piece  of  thin  brass  wire. 

The  patient  should  be  provided  with  two  complete  canulas 
so  as  to  occasionally  be  able  to  withdraw  the  outer  tube  also 
and  cleanse  it  thoroughly.  This  can  be  done  after  a  couple 
of  days,  the  wound  having  had  time  to  assume  the  shape  of 
the  outer  canula,  thus  enabling  it  to  remain  patulous  for  a 
short  time  after  the  instrument  has  been  withdrawn  complete. 
The  extra  canula,  previously  warmed  to  avoid  exciting  cough, 
should  be  introduced  immediately  upon  the  withdrawal  of 

Fig.  93- 


Cohen's  canula  pilot. 

the  other,  using,  to  assist  its  entrance,  a  pilot,  such  as  that 
shown  in  Fig.  93,  invented  by  Dr.  Cohen.  This  instrument, 
introduced  into  the  outer  canula,  presents  a  blunt-pointed 
knob  which  separates  what  tissues  might  impede  the  progress 
of  the  latter.  It  should,  of  course,  be  instantly  withdrawn 
as  soon  as  the  tube  is  in  position.  The  occasional  (once 
or  twice  a  week  after  the  first  few  days)  withdrawal  of  the 
tubes  serves  also  to  avoid  what  danger  the  corrosion  of  a 
metallic  canula  might  incur.  Cases  have  been  reported  in 
which  pieces  of  such  a  cauula,  broken  off  at  an  eroded 
point,  occasioned  alarming  symptoms. 

Occasionally,    granulations    are    formed    at    the    external 


408         ARTIFICIAL   OPENINGS   INTO   THE   LARYNX   AND   TRACHEA. 

tracheal  orifice,  and  in  the  trachea  itself,  the  latter  being 
especially  the  case  when  a  fenestrated  tube  is  employed. 
Strong  astringent  solutions  sometimes  suffice  to  destroy 
them;  in  some  cases,  however,  surgical  measures  are  neces- 
sary. 

When  the  canula  is  to  be  withdrawn  permanently,  the 
natural  breathing  powers  of  the  patient  should  be  tested 
by  closing  the  aperture  of  the  canula  with  a  stopper.  If 
this  is  borne  without  difficulty,  the  instrument  may  be 
withdrawn,  but  kept  within  easy  reach,  with  pilot  in  posi- 
tion, for  sudden  replacing  if  necessary.  As  a  rule,  however, 
this  is  not  required,  and  the  wound  closes  up  after  a  few 
days  to  finally  heal  completely  a  week  or  two  later. 

The  canula  has  occasionally  to  be  worn  permanently,  the 
patient,  to  speak,  being  obliged  to  place  his  finger  upon 
the  external  opening.  In  this  case,  Luer's  tracheotomy- 
tube,  the  inner  canula  of  which  contains  a  silver  pea,  whose 
object  is  to  arrest  the  expired  current  of  air,  so  as  to 
enable  it  to  pass  between  the  vocal  bands,  will  be  found 
very  useful,  rendering  the  use  of  the  finger  to  close  the 
tube  unnecessary. 


APPENDIX. 


To  the  methods  of  treatment  described  in  tjie  body  of 
the  work,  the  author  has  thought  it  advisable  to  add  a  list 
of  the  formulae  which  he  has  found  to  possess  special 
merit.  To  these  are  added  selections  from  the  several 
therapeutic  measures  proposed,  within  the  last  two  years, 
by  different  authors.  The  names  of  the  latter  are  given  in 
each  case;  the  author's  formulae,  however,  will  bear  no 
name. 

ACUTE   CORYZA. 

R     Hydrochlorate  of  cocaine        .        .        .      gr.  vj. 
Subcarbonate  of  bismuth        .         .         .       5SS- 
Talc.          .......       5i§s- 

M.     Use. — Enough  to  cover  a  silver  five-cent  piece  insufflated  into 
each  nostril  every  two  hours. 

R     Nitrate  of  pilocarpine     ....  gr.  viij. 

Tinct.  of  aconite  root      ....  5SS- 

Tinct.  of  belladonna         ....  n^x. 

Tinct.  of  veratrum  viride         .         .         .  n^x. 

Syrup  of  orange  peel,  enough  to  make  .^ij. 
M.     Use. — For  severe  cold.    One  teaspoon ful  every  two  hours  three 
times,  then  every  three  hours,  remaining  in-doors. 

R     Purified  chloroform          ....       5'j- 

Glycerine 

French  brandy,  of  each  .         .         .       SJ- 

M.     S. — One  teaspoonful  in  water  every  three  hours. 

(409) 


410  APPENDIX. 

Dr.  Grcntilhomme. — One-half  milligr.  sulphate  of  atropine  in  violent 
cases.  Effective  when  prescribed  early. — France  Medicate, 

Dr.  M.  Ffalliott. — A  quinine  spray,  gr.  vj  in  the  ounce  of  water, 
arrests  early  symptoms  in  twelve  hours. — British  Med.  Journal. 

Dr.  J.  L.  Davis. — Tartar  emetic,  gr.  ss  to  water,  one  ounce.  One 
teaspoonful  every  quarter  of  an  hour  four  times,  then  every  three 
hours. — Medical  Brief 

Dr.  S.  Soils  Cohen. — Salicylate  of  ammonium  gr.  x-xv,  repeated 
every  second  hour  until  tinnitus  aurium  is  produced.  Indicated  in 
later  stages. — Medical  Times. 

Dr.  J.  E.  Dobson  (British  Army). — 5SS-  camphor  in  shaving  jugful 
of  boiling  water.  A  cone  of  paper  is  placed  over  the  jug,  the  end 
of  the  cone  at  opening,  the  base  being  used  to  introduce  the  face. 
Breathe  freely  from  ten  to  twenty  minutes,  and  repeat  three  or  four 
times  in  as  many  hours. — London  Lancet. 

Dr.  J.  M.  Gross,  Marietta,  Ga. — In  fully  established  case,  with 
cough,  bryonia  gr.  ss-j  every  hour  or  two.  When  expectoration  is 
difficult,  gr.  £-^  bichromate  of  potash. —  Chicago  Med.  Times. 

Dr.  Sandras. — Inhalations  of  the  fumes  of  100  gram,  of  turpen- 
tine poured  on  20  gram,  of  Norwegian  tar. — Bulletin  de  V Academic 
de  Medecine. 

SIMPLE   CHRONIC   AND   HYPERTROPHIC   RHINITIS. 
WASHES. 

Dobell's  Solution  : — 

R     Carbolic  acid,  liq.        .....       n^xxx. 

Biborate  of  sodium    ..... 

Bicarbonate  of  sodium,  of  each         .         •       5j- 
Glycerine     ....... 

Water,  enough  to  make     .... 

M. — To  be  used  with  atomizer. 


APPENDIX.  411 

Dr.  C.  E.  Bean,  St.  Paul,  Minn.  :— 

R     Salicylate  of  sodium 5U- 

Borate  of  sodium 5iij- 

Glycerine S^s. 

Water  enough  to  make       .         .         .  svj. 

M.  Use. — Dessertspoonful  in  one  pint  water.  To  be  used  with 
spray  or  as  douche. 

Dr.  David  Newman,  Glasgow  : — 

R     Bicarbonate  of  sodium       .         .         .         •       5j- 

Carbolic  acid gr.  xx. 

Glycerine    .         .         .         .         .         .         .       ^ss. 

Water  enough  to  make      ....      siv. 

M.     Use. — To  be  used  with  atomizer. — British  Med.  Journal. 

Prof.  D.  Hayes  Agnew,  Philadelphia. — Sage  tea  used  as  douche. 
Detergent,  and  credited  with  curative  properties. —  Therapeutic  Gazette. 

Dr.  J.  N.  Mackenzie,  Baltimore. — Solution  of  bichloride  of  mercury 
gr.  j  to  one  pint  of  water,  adding  sij  cherry  laurel  water. -^-Maryland 
Med.  Journal. 


Dr.  E.  Rosen  thai,  New  York. — Eucalyptol,  5j5  i11  an  eight-ounce 
vial,  adding  boiling  water.  Used  as  an  inhalant  twice  or  three  times 
daily. — Am.  Med.  Digest. 

Drs.  Masini  and  Massei. — Resorcin,  one-half  to  one  per  cent,  solu- 
tion used  with  atomizer,  twice  daily,  four  minutes  each  time. — France 
Medical e. 

TABLETS.* 

1.     R     Borate  of  sodium    .         .         .         .         •       9j- 
Bicarbonate  of  sodium  .         .         .       9iss. 

Carbolic  acid gr.  iij. 

For  one  tablet ;  to  be  dissolved  in  Oj  water,  at  100°  F. ;  used 
with  atomizer,  three  or  four  minutes  three  times  daily,  as  detergent. 

*  Made  by  Mr.  W.  H.  Llewellyn,  pharmacist,  Philadelphia. 


412  APPENDIX. 

2.  R     Chlorate  of  potassium     ....       9ij. 

Salicylate  of  sodium        ....       gr.  xx. 
For  one  tablet ;   to  be  used  as  above. 

Astringent  Tablets  : — 

3.  R     Ext.  of  hydrastis  canad.         .         .         .       9ij. 

Ext.  of  Canadian  pine    ....       gr..  xx. 
Borate  of   sodium   .....       5SS- 
For  one  tablet ;   to  be  used  as  above. 

4.  R     Tannic  acid      .         .         .         .         .         .       gr.  9ij. 

Gallic  acid        ......       gr.  xx. 

Bicarbonate  of  sodium   ....       5ss. 

For  one  tablet ;   to  be  used  as  above. 

5.  R     Sulpho-carbolate  of  zinc         .         .         •       3j- 

Biborate  of  sodium         ....       5SS- 
For  one  tablet ;   to  be  used  as  above. 

FLAT   BOUGIES.* 

1.  R     Ext.  of  belladonna  ....       gr.  ij. 

Ext.  of  hydrastis gr.  v. 

For  one  bougie. 

2.  R     Hydrochlorate  of  cocaine        .         .  gr.  j. 

Extract  of  ergot     .         .         -.         .         .       gr.  iij. 
For  one  bougie. 

3.  R     Extract  of  erythroxylon  coca 

Extract  of  Canadian  pine,  of  each        .       gr.  v. 
For  one  bougie. 

4.  R     Extract  of  opium    .....       gr.  j. 

Extract  of  krameria        ....       gr.  ij. 
For  one  bougie. 

*  Made  by  Messrs.  Foote  &  Swift,  Philadelphia. 


APPENDIX.  413 

5.     R     Sulphate  of  zinc gr.  ss. 

Extract  of  opium  ....       gr.  iss. 

For  one   bougie. 


6.     R     Hydrochlorate  of  cocaine       .         .         .       gr.  j. 

Tannic  acid gr.  iij. 

For  one  bougie. 


7.      R     Extract  of  haraamelis     .         .         .         .       gr.  v. 
Hydrastine  (alkaloid)  gr.  iij. 

M.     S. — For  one  bougie. 


8.      R     Resorcine gr.  ss. 

Extract  of  hamamelis      ...  gr.  v. 

Hydrochl.  of  cocaine      ....  gr.  ss. 
M.     S. — For  one  bougie. 


OINTMENTS. 

1.  R     Acetate  of  morphia         .         .         .  gr.  iv. 

Tannic  acid      ...... 

lodoform,  of  each 5§s- 

Vaseline £ss. 

M.     S. — To  be  applied  to  nostrils  with  cotton  pledget. 

2.  R     Gallic  acid 5ss. 

Belladonna  ointment        .... 

Cosmoline,  of  each 5ij- 

M.     S. — Apply  with  cotton  pledget. 

3      R     Yellow  sulphate  of  mercury    .         .         .       gr.  iij. 

Cosmoline sss. 

M.     S. — Apply  with  cotton  pledget. 


414  APPENDIX. 

Dr.  A.  Y.  Banes,  St.  Joseph,  Mo. : — 

R     Oil  of  eucalyptus 5U- 

Bee's  wax          ......  Sj- 

Boracic  acid     ......  5iij- 

Vaseline,  enough  to  make       .         .  3j. 

M. — Dissolve  the  wax  in  the  vaseline  and   add  other  ingredients. 
S. — Apply    to   the   nostrils    and    assume    recumbent    position    to 
cause   ointment   to   run   back   to   posterior   cavity. 

POWDERS. 

Dr.  Lefferts,  of  New  York  :— 

R     Salicylic  acid   .         .         .         .         .  gr.  x. 

Tannic  acid       .         .         .         .         .         •  3j- 

Subcarb.  of  bismuth        .         .         .         •  5j- 

— Nasal   Catarrh,  St.  Louis,  1884. 

Dr.  M.  Mackenzie,  London  : — 

R     Tannic  acid,  powdered     ....  gr.  v. 

lodoform,  "  ....  gr.  ij. 

Gum  acacia,          "  ....  gr.  iij. 

—  Throat  Hosp.  Pharm. 

Dr.  Whistler,  of  London  : — 

R     Carbonate  of  Bismuth     ....  gr.  vii. 

Acetate  of  Morphia         ....  gr.  £ . 

lodoform gr.  v. 

Gum  acacia       ......  gr.  v. 

—  Throat  Hosp.  Fharm. 

Dr.  Beverly  Robinson,  New  York: — 

R     Sulphate  of  morphia       .         .         .  gr.  j- 

Belladonna  leaves,  pulverized          .         .  gr.  x. 

Calomel gr.  xx. 

Bicarbonate  of  soda         ....  gr.  xv. 

Acacia,  pulverized 5SS- 

M.  — Nasal  Catarrh,  etc.,  New  York,  1885. 


APPENDIX.  415 

ATROPHIC   RHINITIS. 

Mr.  Edw.  "Woakes,  London  Throat  Hospital : — 

R     Boracic  acid     ......       gr.  Ix. 

Glycerine 

Water       ....... 

Cotton  wool,  a  thin  sheet       .         .         • 
Mix  the  boracic  acid,  glycerine  and  water,  and  dissolve  with  the 
aid  of  heat.     Saturate  the  wool  evenly  with  the  solution  and  dry  by 
exposure  to  the  air  with  a  moderate  heat. 

Use. — (See  Gottstein's  cotton  wool  tamrons,  p.  120.) 

Dr.  Frank  P.  Foster,  New  York  : — 

R     lodoform  .         .         .         .         .         .       Jss. 

Oil  of  Eucalyptus  .         .         .         . .      n^iv 

Vaseline 3ss. 

M.  Use. — (See  Gottstein's  cotton  wool  tampons,  p.  120.)  Excel- 
lent ointment  in  atrophic  and  sj-philitic  rhinitis. 

HAY  FEVER. 

Dr.  W.  Judkins,  Cincinnati. — Hydriodic  acid  syrup,  one  teaspoon- 
ful  every  two  hours.  Pure  acid,  three  to  five  drops  on  sugar. — N.  Y. 
Med.  Record. 

Dr.  W.  F.  Phillips. — Succus  belladonnae,  one  minim  every  hour. — 
Med.  Bulletin. 

Dr.  O'Connell. — Small  pieces  of  cotton  wool  saturated  with  gly- 
cerine introduced  in  each  nostril. — Med.  Bulletin. 

ACUTE   PHARYNGITIS. 
1.*     R     Hydrochlorate  of  cocaine         .         .         . 

Chlorate  of  potash 

Acacia  and  sugar     ..... 
Black  currant  paste  .         .         .         .       s.  q 

M. — For  one  lozenge. 
Use. — One  every  two  hours. 


*  The  numbered  lozenges  are  made  by  Mr.  W.  H.  Llewellyn,  Philadelphia. 


416  APPENDIX. 

2.  R     Borate  of  sodium     .         .         . 

Chlorate  of  potash,  of  each     .         .  gr.  ij. 

Acacia,  sugar  and  black  currant  paste       .  s.  q. 
M. — For  one  lozenge. 

Use. — One  every  two  hours  when  the  throat  is  dry. 

3.  R     Resin  of  guaiac        .....  gr.  iss. 

Borate  of  sodium     .....  gr.  iss. 

Chloride  of  ammonium    ....  gr.  j. 

Acacia,  sugar  and  black  currant  paste       .  s.  q. 
M. — For  one  lozenge. 
Use. — One  every  two  hours  in  earl}*  stages. 

Dr.   C.   L.  Mitchell,  Philadelphia:—* 

R     Ext.  Hyoscyamus     .....  gr.  j1^. 

Aqueous  ext.  of  opium   ....  gr.  ?V 

Fid.  ext.  ipecac         .         .         .         .         .  gr.  |. 

Fid.  ext.  wild  cherry        ....  gr.  j. 

Gelatin       .         .         .         .         .         .  s.  q. 

Use. —  One  every  two  hours. 

CHRONIC   PHARYNGITIS. 

4.  R     Carbolic  acid     .         .         .         .  gr.  ^. 

Cubebs       .         .         .         .         .         .  gr.  j. 

Rhatany      .......  gr.  ij. 

Chlorate  of  potash  .....  gr.  ij. 

Acacia,  sugar  and  black  currant  paste       .  s.  q. 
M. — For  one  lozenge. 

Use. — Valuable   for    singers,   in   whom    a    relaxed    throat    causes 
frequent   hoarseness. 

5.  R     Hydrochlorate  of  cocaine         .         .         .  gr.  ^. 

Benzole  acid      ......  gr.  ss. 

Cubebs gr.  j. 

Chlorate  of  potash  .....  gr. 

Licorice,  acacia  and  sugar  s.  q. 
M.     Use. — One  every  hour. 
Useful  in  subacute  exacerbations  of  chronic  phaiyngitis. 

*  Dr.  Mitchell's  lozenges  are  made  by  Messrs.  C.  L.  Mitchell  &  Co.,  Philadelphia. 


APPENDIX. 

Dr.  C.  L.  Mitchell,  Philadelphia:— 

R     Hydrastis  canad <rr.  ij. 

Gelatine s.  q. 

Use. — One  every  three  hours,  in  later  stages. 

6.  R     Extract  of  lettuce gr.  iss. 

Cocleia gr.  ss. 

Extract  of  Ir^oscyamus    ....       gr.  ss. 

Gelatine,  acacia  and  sugar       .         .  s.  q. 

M.     Use. — One  every  two  hours. 

Rapidly  effective  in  subacute  exacerbations  of  chronic  pharyngitis. 
Should  not  be  used  by  singers  within  an  hour  before  singing. 

7.  R     Chloride  of  ammonium    ....       gr.  ij. 

Chloride  of  potash  ....       gr.  j. 

Acacia,  sugar  and  licorice        .         .  s.  q. 

M.     Use. — Valuable  in  atrophic  or  dry  pharyngitis. 

TONSILLITIS. 

8.  R     Hydrochlorate  of  cocaine         .         .  gr.  £. 

Resin  of  guaiac         .....  gr.  ij. 

Carbolic  acid     .         .         .         .         .  gr.  £. 

Acacia,  sugar  and  red  currant  paste       .  s.  q. 

M.     Use. — This  lozenge  will  arrest  tonsillitis  in  a  few  hours,  if 
administered  early,  one  ever}'  hour. 

Dr.  Gine,  of  Bruxelles. — Bicarbonate  of  soda  to  inflamed  tonsils, 
insufflated,  or  applied  with  finger. — Presse  Medicale  Beige. 

Dr.  Hormedzdji. — Salic3'late   of  sodium,  gr.  xv,  every   hour   until 
urgent  symptoms  relieved,  then  reduce  to  half.     Use  as  gargle. 

R     Salicylate  of  sodium         .         .         .  gr.  x. 

Glycerine 3j. 

Water 5iij. 

M.  — Lancet  and   Clinic. 

27 


418  APPENDIX. 

Dr.  II.  G.  Houston. — Fluid  extract  of  eucalyptus,  one  teaspoonful 
in  one  ounce  of  Aval  IT  as  hot  as  can  be  borne  ;  gargle  and  spray  every 
twenty  minutes. — Atlantic  Journal  of  Med. 

HYPERTROPHIED   TONSILS. 

Dr.  Moresco,  of  Cadiz,  Spain. — Acetic  acid,  interstitial  injections. — 
lie,  vista  de,  Med.  y  C/iir.  Pr act  tea. 

Dr.  Chisholm. — Chloride  of  zinc.  Saturated  solution,  introduced 
into  crypts  with  cotton  pledget. — Southern  Med.  Record. 

Dr.  J.  Gr.  Partagas. — Bicarbonate  of  sodium,  applied  three  times 
daily  with  linger,  over  surface  of  tonsils,  brings  on  gradual  resolution. — 
.London  Lancet. 

RELAXED  PALATE  AND  UVULA. 
9.   R  Alum    .......   gr.  ij. 

Borate  of  sodium      .....       gr.  j. 

Rose  leaves gr.  ij. 

Acacia,  sugar  and  black  currant  paste       .       s.  q. 
M. — For  one  lozenge. 
Use. — One  every  three  hours. 

10.  R     Extract  of  rhatany  ....       gr.  ij. 

Tannic  acid.       .         .         .         .         .         .       ja'j. 

Acacia,  sugar  and  red  currant  pas.e      .       s.  q. 
M.     Use. — One  every  three  hours. 

SUBACUTE  LARYNGITIS. 

In  ordinary  hoarseness  Nos.  1  and  6  lozenges  will  be  found  very 
effective;  for  singers,  however,  No.  4,  or  the  following  will  be  more 
satisfactory  : — 

11.  R     Benzoic  acid      ......       gr.  jr> 

Borate  of  sodium gr.  iss. 

Acacia,  sugar  and  red  currant  paste       .       s.  q. 
M.     Use. — One  every  hour. 
Frequently  succeeds  in  checking  early  symptoms. 


APPENDIX.  419 

12.  R     Erythroxylon  coca gr.  ij. 

Hydrochlorate  of  cocaine         .         .         .  gr.  |. 

Licorice,  sugar  and  acacia        .         .  s.  q. 
M.     Use. — One  every  two  hours. 
Valuable  in  severe  cases  complicated  with  dysphagia. 

13.  R     Cubebs gr.  ss. 

Dover's  powder          .....  gr.  ij 

Licorice,  sugar  and  acacia        .         .  s.  q. 

M.     Use. — One  every  three  hours. 

A  very  effective  lozenge  during  the  entire  course  of  the  affection, 

Dr.  Corson. — Diaphoretics  in  aphonia.  Nitrate  of  potassium,  51), 
or  infusion  of  jaborandi  made  by  placing  9ij  of  the  leaves  in  a  small 
cup  of  boiling  water. — Braithwaite'ls  Retrospect* 

Dr.  L.  Jurist,  Philadelphia : — 

R     Fid.  ext.  coca  leaves         .        .        .        .  gr.  v. 

Tinct.  aconite  root    ,  gr.  ^. 

Tinct.  belladonna       .....  gr.  j. 

Gelatine s.  q. 

M.     Use. — One  every  two  hours. 

Dr.  C.  L.  Mitchell,  Philadelphia:— 

R     Benzoic  acid gr.  £. 


Camphor gr. 


Resin  guaiac     ...  .         .       gr.  |-. 

Gelatine s.  q. 

M.     Use. — One  ever}1  three  hours. 

CHRONIC   LARYNGITIS. 

For  this  affection  the  choice  of  the  agents  to  be  administered 
should  be  guided  by  the  degree  of  secretion  present.  When  this 
is  slight,  an  anodyne  lozenge,  such  as  No.  6  or  No.  7,  alternating 
with  an  astringent  one,  such  as  No.  9,  will  be  found  efficacious. 
When  the  secretion  is  profuse,  local  stimulation  and  astringency 
are  required. 


420  APPENDIX. 

14.  R     Benzole  acid gr.  ^. 

A  him          .......  gr.  ij. 

Chlorate  of  potassium      .         .         .  gr.  j. 

Licorice,  acacia  and  sugar  s.  q. 
M.     Use. — One  every  three  hours. 

15.  R     Oleo-resin  of  cubebs         .         .         .  n^ss. 

Resin  of  guaiac gr.  j. 

Oil  of  sassafras n^. 

Tolu,  acacia  and  sugar  s.  q. 
M.     Use. — One  every  three  hours. 

16.  R     Oil  of  eucalyptus n^. 

Oil  of  tar n^. 

Ext.  of  Canadian  pine     ....  'gr.  j. 

Acacia,  sugar  and  black  currant  paste       .  s.  q. 
M.     Use. — One  every  four  hours. 

Dr.  C.  L.  Mitchell,  Philadelphia:— 

R     Bromide  of  potassium      .         .         .  gr.  iij. 

Gelatine s.  q. 

Use. — One  every  hour  when  there  is  pain. 

TUBERCULOUS  LARYNGITIS. 
Dr.  Felix  Semon,  of  London  : — 

R    lodoform  ....... 

Boracic  acid,  of  each       .....       gr.  j. 

O         »J 

Acetate  of  morphia  ....       gr.  ^. 

M.     Use. — For  one  insufflation.  — Lancet, 

Dr.  Fletcher  Ingals,  of  Chicago : — 

R     Sulphate  of  morphia         ....       gr.  iv. 

Carbolic  acid     ...... 

Tannic  acid,  of  each         ....      3iss. 

Glycerine  ....... 

Water,  of  each Jiv. 

M.     Use. — To  be  applied  to  larynx  with  brush. 

—Med.  World. 


APPENDIX. 

17.      R     Hydrochlorate  of  cocaine         .        .  gr.  £. 

Borax gr.  ij. 

Gum  acacia gr.  ij. 

Marshmallow  root gr.  ij. 

M. — Macerate  marshmallow  in  orange-flower  water  twelve  hours; 
strain,  then  add  cocaine,  borax  and  acacia;  evaporate  to  consistency 
of  honey,  with  constant  stirring,  and  add  gradually  white  of  eg . 
beaten  up  with  more  orange-flower  water.  Evaporate,  stirring  till 
paste  will  not  adhere  to  hands. 

(Process  employed  for  the  London  Throat  Hospital  marshmallow 
lozenge.) 

Use. — To  be  dissolved  slowly  in  the  mouth  ten  minutes  before 
meals,  or  when  required  by  the  paiu. 


INDEX. 


Abduction  of  the  vocal  bands,  302 
Abductor  paralysis  of  the  larynx,  364 
Abscess  of  the  septum,  169 
retro-pharyngeal,  272 
Acacia  in  medication  of  the  larynx,  326 
Accumulators  for  electric  lighting,  9 
Acetate  of  lead  in  chronic  posterior  nasal 

pharyngitis,  228 
epistaxis,  209 
syphilitic  pharyngitis,  271 
therapeutic  properties  of,  56 
Acid  nitrate  of  mercury  in  syphilitic  phar- 
yngitis, 271 
Aconite  root,  tincture  of,  in  acute  rhinitis, 

68 

subacute  laryngitis,  329 
tonsillitis,  284 
Actual  cautery  in  folliculous  pharyngitis, 

260 

naso-pharyngeal  polypus,  238 
Acute  catarrh  of  the  naso-pharynx,  216 
larynx,  330 
pharynx,  250 
catarrhal  laryngitis,  330 
coryza,  64 
laryngitis,  330 

etiology  of,  330 
pathology  of,  330 
prognosis  of,  332 
symptoms  of,  331 
treatment  of,  332 
nasal  bleu  nor  rhcea,  64 

catarrh,  64 
pharyngitis,  250 

etiology  of,  250 
pathology  of,  250 
prognosis  of,  251 
symptoms  of,  250 
treatment  of,  252 
post-nasal  catarrh,  216 
posterior  nasal  pharyngitis,  216 


Acute  posterior  nasal  pharyngitis,  etiology 
of,  216 

pathology  of,  216 
prognosis  of,  218 
symptoms  of,  217 
treatment  of.  218 
retro-nasal  catarrh,  216 
rhinitis,  64 

etiology  of,  64 
pathology  of,  65 
prognosis  of.  67 
symptoms  of.  66 
treatment  of,  67 
rhinorrhoea,  64 
sore  throat,  250 

Adams'  operation  for  deviated  septum,  166 
septum    forceps,  author's   modification 

of,  Fig.  50,  M6 

Adduction  of  the  vocal  bands,  302 
Adductor  paralysis  of  the  larynx,  366 
Adenoid  vegetations  at  the  vault  of  the 

pharynx,  229 

Adenomata  of  the  pharynx,  220 
After-effects  of  local  treatment  in  hay  fever, 

200 

After-treatment  of  tracheotomy,  405 
Air  compressor,  Burgess',  Fig.  18,  39 
Albo-carbon  light,  Fig.  5,  6 
Allen,  Harrison,  on  hay  fever,  171 

on  pathology  of  septal  deviation,  161 
galvano-cautery  snare,  Fig.  37,  105 
nasal  cotton  carrier,  Fig.  20,  42 
nasal  specula,  Fig.  34,  101 
Alteratives  in  medication  of  mucous  mem- 
branes, 59 

tuberculous  laryngitis,  347 
Alum  in  acute  rhinitis,  69 
chronic  laryngitis,  342 
epistaxis,  208 

hypertrophy  of  the  tonsils,  289 
in  mucous  polypi  of  the  nose,  139 

(423) 


424 


INDEX. 


Alum  in  acute  relaxation  of  soft  palate  and 
uvula,  297 

f?imple  chronic  rhinitis,  77,  84 

syphilitic  pharyngitis,  271 

spray  in  acute  laryngitis,  333 

therapeutic  properties  of,  57 
Ammonia,  muriate  of,  in  atrophic  pharyn- 
gitis, 265 

valerianate  of,  in  hay  fever,  203 

hysterical  aphonia,  375 
Ammoniaeum   in    chronic    posterior   nasal 

pharyngitis,  229 

Ammonium,  chloride  of,  in  acute  rhinitis, 
68 

atrophic  rhinitis,  118 

therapeutic  properties  of,  53,  58 
Amygdalitis,  281 
Anatomy  of  anterior  nasal  cavities,  12 

larynx,  300 

pharynx,  239 

posterior  nasal  cavity,  17 
Angina  catarrhalis,  250 

faucium,  281 

tonsillaris,  281 

Angiomata  of  the  larynx,  381 
Anodynes  in  membranous  pharyngitis,  262 

tuberculous  laryngitis,  347 
Anosmia,  204 

etiology  of,  204 

treatment  of,  205 
Anterior  nasal  cavities,  diseases  of,  64 

tumors  of,  136 

rhinoscopic  image,  25 

rhinoscopy,  22 

Anti-spasmodics  in  spasm  of  the  larynx,  377 
Aperients  in  membranous  pharyngitis,  262 
Aphonia,  nervous,  374 

hysterical,  374 
Aphthous  sore  throat,  261 
Arsenic,  in  hay  fever,  201 

hysterical  aphonia,  375 

paralysis  of  the  pharynx,  277 

Fowler's  sol.  of,  in  scrofulous  rhinitis, 

135 
Artificial   openings   into   the    larynx    and 

trachea,  398 

Assafoetida  pill  in  hay  fever,  201 
Astringents   in    hypertrophy  of   the  ton- 
sils, 288 


Astringents  in  medication  of  nasal  cavities, 

55 

tuberculous  laryngitis,  347 
Atomizer,  Lentz's,  Fig.  78,  318 

author's  pharyngeal,  Fig.  65,  245 
post  nasal,  Fig.  60,  224 
Snowden's,  Fig.  19,  41 
Sass',  Fig.  17,  38 
Atrophic  catarrh,  114 
pharyngitis,  263 
etiology  of,  263 
pathology  of,  263 
prognosis  of,  264 
symptoms  of.  263 
treatment  of,  264 
rhinitis,  114 

etiology  of,  114 
pathology  of,  115 
prognosis  of,  117 
symptoms  of,  116 
treatment  of,  118 
Author's  anterior  sensitive  area  in  the 

nose,  181 
operation    for    deviation    of    septum, 

167 

Auto-insufflator,  author's,  Fig.  27,  48 
use  of,  in  syphilitic  rhinitis,  130 
posterior,  author's,  Fig.  61,  226 
Autumnal  catarrh,  170 

Bath,  warm,  in  spasm  of  the  larynx,  377 
Bathing  in  scrofulous  rhinitis,  134 
Battery,  galvano-cautery,  author's,  Fig.  32, 

98 

Beclard  on  causes  of  deviation  of  the  sep- 
tum, 161 

Belladonna  cigarettes  in  hay  fever,  204 
bougies  in  simple  chronic  rhinitis,  82 
in  acute  laryngitis,  332 

pharyngitis,  252 
chronic    posterior    nasal    pharyngitis, 

227 

hay  fever,  203 

sarcoma  of  the  nasal  cavities,  158 
infusion  inhalations  in  tonsillitis,  285 

tuberculous  pharyngitis,  267 
ointment  in  hay  fever,  203 

simple  chronic  rhinitis,  83 
therapeutic  properties  of,  61 


INDEX. 


425 


Bellocq's  canula  in  position,  Fig.  57,  210 

when  not  in  use,  Fig.  56,  209 
Beard,  on  etiology  of  hay  fever,  171 
Bent  tip  curette,  Fig.  59,  213 
Benzoin  infusion  inhalations  in  tonsillitis, 

285 

therapeutic  properties  of,  61 
Biborate  of   sodium   (borax)   in    atrophic 

rhinitis,  118 
chronic  laryngitis,  340 
hay  fever,  203 

malignant  tumors  of  the  larynx,  392 
simple  chronic  rhinitis,  75 
syphilitic  laryngitis,  353,  355 
tuberculous  laryngitis,  347 
tuberculous  pharyngitis,  267 
therapeutic  properties  of,  53 
Bicarbonate  of  sodium  in  acute  posterior 

nasal  pharyngitis,  218 
hay  fever,  203 
hypertrophic  rhinitis,  109 
simple  chronic  rhinitis,  75 
syphilitic  laryngitis,  355 
tuberculous  laryngitis,  347 
therapeutic  properties  of,  53 
Bichloride  of  mercury  in  chronic  posterior 

nasal  pharyngitis,  228 
scrofulous  rhinitis,  135 
Bigelow,  on  anatomy  of  the  nasal  cavities,  16 
Bismuth,  in  chronic  posterior  nasal  phar- 
yngitis, 227 

medication  of  the  larynx,  326 
syphilitic  rhinitis,  130 
subnitrate  as  a  protective,  62 
in  simple  chronic  rhinitis,  78 
Bistoury  in  removal  of  ecchondromata  of 

nasal  cavities,  152 

Blackley  on  etiology  of  hay  fever,  170 
Blades  and   punches   for   author's  septum 

forceps,  1<;7 
Blandin's,  operation   for   deviation,  of  the 

septum,  166 
Blennorrhcea,  acute  nasal,  64 

chronic,  71 
Bone-forceps,  nasal,  Fig.  52,  168 

Mackenzie's,  Fig.  45,  144 
Bonwill's  surgical  engine,  Fig.  48,  156 
Boracic    acid    in    chronic   posterior   nasal 
pharyngitis,  227 


Boracic  acid,  therapeutic  properties  of,  58 
Boro-glyceride    bougies    in  simple  chronic 

rhinitis,  82 

Bostock  on  hay  fever,  170 
Bosworth  on  etiology  of  chronic  laryngitis, 

337 

on  etiology  of  abductor  paralysis,  366 
treatment  pf  tonsillitis,  285 

tuberculous  laryngitis,  346 
spasm   of   the   glottis   as   a   result  of 

elongated  uvula,  296 
nostril  dilator,  Fig.  8,  23 
probe,  Fig.  31,  96 
Bougies  in  simple  chronic  rhinitis,  79 

medicated  gelatine,  in  simple  chronic 

rhinitis,  80 

metallic,  in  simple  chronic  rhinitis,  80 
Bromide  of   potassium    in   acute   rhinitis, 

68 

simple  chronic  rhinitis,  84 
therapeutic  properties  of,  54 
Browne,  Lennox,  dangers  in  the  removal 

of  laryngeal  tumors,  389 
on  the  use   of  sprays  in  the  larynx, 

324 

hamamelis  in  hay  fever,  203 
Bruns,    Paul,     classification     of  laryngeal 

papillomata,  380 

Bull-eye  condenser,  Mackenzie's,  5 
Burgess'  air  compressor,  Fig.  18,  39 
Burrs  for  surgical  engine,  Fig.  49,  157 

Calomel  in  chronic  posterior  nasal  pharyn- 
gitis, 227 

scrofulous  rhinitis,  135 

simple  chronic  pharyngitis,  254 

simple  chronic  rhinitis,  77 

syphilitic  rhinitis,  130 

therapeutic  properties  of,  60 
Camphor  in  subacute  laryngitis,  329 

therapeutic  properties  of,  58 
Canula,  Bellocq's,  in  position,  Fig.  57,  210 

when  not  in  use,  Fig.  56,  209 
Capart's   method    of    removing    post-nasal 

adenoid  growth?.  234 
Carbolic  acid  in  acute  rhinitis,  70 

atrophic  rhinitis,  119 

hay  fever,  195 

mucous  polypi  of  the  nose,  140 


426 


INDEX. 


Carbolic  acid  in  simple  chronic  rhinitis,  70 
syphilitic  rhinitis,  128,  130 
inhalations  in  hay  fever,  203 
therapeutic  properties  of,  54,  58 
Carbolized     iodo-tannin,    glycerite    of,    in 
chronic  posterior  nasal  pharyngitis, 
228 

scrofulous  rhinitis,  76 
simple  chronic  rhinitis,  135 
Carcinoma  of  nasal  cavities,  159 
pathology  of,  159 
prognosis  of,  159 
symptoms  of,  159 
treatment  of,  159 
Cascara   sagrada  in  folliculous  pharyngitis, 

259 
Chassaignac's    operation    to    expose   nasal 

cavities,  148 

Castor  oil  in  subacute  laryngitis,  329 
Catarrh,  atrophic,  114 
chronic  nasal,  71 
dry,  114 
fetid,  130 

of  larynx,  acute,  330 
of  naso-pharynx,  acute,  216 

chronic,  218 

Catarrh  of  pharynx,  acute,  250 
post-nasal,  218 
purulent,  71 
retro-nasal,  218 
specific,  122 
strumous,  130 
Catarrhal  laryngitis,  327 

acute,  330 

Catarrhus  pestivus,  170 
Caustic  acids  in  retro-pharyngeal  polypus, 

238 

Caustics  in  laryngeal  tumors,  382 
Cautery-knife  in  position,  for  cauterization 

in  hay  fever,  Fig.  54,  192 
loop,  post-nasal,  in  position,  Fig.  63, 

233 
Chlorate  of  potash  lozenges  in  membranous 

pharyngitis,  262 
solution  in  atrophic  pharyngitis,  264, 

265 

Chloride  of  ammonium  in  acute  rhinitis,  68 
atrophic  rhinitis,  118 
therapeutic  properties  of,  53,  58 


Chloride  of  sodium,  therapeutic  properties 

of,  5 1 

Chloride  of  zinc  in  chronic  laryngitis,  342 
posterior  nasal  pharyngitis,  228 
therapeutic  properties  of,  56 
Chloroform  in  maggots  in  the  nose,  214 

therapeutic  properties  of,  61 
Chromic    acid   applicator,   nasal,   Fig.   39, 

108 
in  hypertrophic  rhinitis,  97 

hypertrophy  of  the  tonsils,  289 
laryngeal  tumors,  382 
medication  of  the  larynx,  326 
nasal  mucous  polypi,  140, 143 

papillomata,  150 
treatment  of  hay  fever,  195 
therapeutic  properties  of,  62 
Chronic  catarrh  of  the  naso-pharynx,  218 

throat.  253 

catarrhal  laryngitis  336 
coryza,  71 
blennorrhcea,  71 
laryngeal  catarrh,  336 
laryngitis,  336 

etiology  of,  336 
pathology  of,  338 
prognosis  of,  340 
symptoms  of,  338 
treatment  of,  340 
nasal  catarrh,  71 
pharyngitis,  simple,  253 
posterior  nasal  pharyngitis,  218 
etiology  of,  219 
pathology  of,  219 
prognosis  of,  222 
symptoms  of,  220 
treatment  of,  223 
rhinitis,  71 
rhinorrhoea,  71 
sore  throat,  253 
Cleansing  and  medicating  the  nasal  cavities, 

instruments  used  in,  33 
the  larynx,  318 
the  pharynx,  244 
Clergyman's  sore  throat,  255 
Coca  bougies  in  simple  chronic  rhinitis,  82 
concentrated    infusion    of,    in    simple 

chronic  rhinitis,  84 
lozenges  in  acute  pharyngitis,  252 


INDEX. 


427 


Coca,  pulv.  ext.  of,  in  nasal  mucous  polypi, 

139 

therapeutic  properties  of,  (U 
wine  of,  in  acute  pharyngitis,  252 
hay  fever,  204 
hysterical  aphonia,  375 
membranous  pharyngitis,  262 
subacute  laryngitis,  329 
Cocaine,  hydrochlorate  of,  in  acids  to  ren- 
der them  painless,  195 
acute  laryngitis,  333 
pharyngitis,  252 
posterior  nasal  pharyngitis,  218 
rhinitis,  70 

amputation  of  tonsils,  294 
chronic  laryngitis,  341,  342 
extraction   of   foreign    bodies   in    the 

larynx,  395 

hypertrophic  rhinitis,  92,  114 
laryngeal  tumors,  382 
malignant  tumors  of  the  larynx,  392 
motor  paralysis  of  the  larynx,  373 
nasal  mucous  polypi,  140 
posterior  rhinoscopy,  29 
sarcoma  of  nasal  cavities,  1 58 
simple  chronic  rhinitis,  77,  84 
subacute  laryngitis,  329 
syphilitic  laryngitis,  355 
therapeutic  properties  of,  58 
tonsillitis,  284 
tuberculous  laryngitis,  347,  348 

pharyngitis,  267 
Codman  &  ShurtlefFs  modification  of  Siegle's 

steam  atomizer,  Fig.  80,  323 
Cohen,  J.  Solis,  on  hypertrophic  posterior 

nasal  pharyngitis,  229 
impaction  of  the  epiglottis,  377 
removal  of  laryngeal  tumors,  383 
treatment  of  acute  laryngitis,  333. 
canula  pilot,  Fig.  93,  407 
electrolysis  needle,  237 
laryngeal  forceps,  author's  modification 

of,  Fig.  22,  43 

pharyngeal  cotton  holder,  Fig.  66,  246 
post-nasal    cutting    forceps,    Fig.   Hi, 

234 

post-nasal  tube,  Fig.  16,  37. 
Cold  in  the  head,  64 
Compresses,  cold,  in  epistaxis,  208 


Conium  juice,  inhalations  in  hay  fever,  203 
tonsillitis,  2-5 

tuberculous  pharyngitis,  2'>7 
therapeutic  properties  of,  <il 
Consumption  of  the  pharynx,  266 

throat,  343 

Contraction  of  the  laryngeal  aperture,  305 
Copper,  sulphate  of,  in  epistaxis,  209 

chronic    posterior    nasal    pharyngitis, 
228 

laryngitis,  341 

simple  chronic  pharyngitis,  255 
therapeutic  properties  of,  50 
Coryza,  acute,  64 
chronic,  71 
fetid,  130 

vasomotoria  periodica,  170 
Cosmoline  in  chronic  laryngitis,  342 
simple  chronic  pharyngitis,  255 

rhinitis,  83 
Cotton  and  bougie  carrier,  Swift's,  Fig.  21, 

42 

carrier,  nasal,  Allen's,  Fig.  20,  42 
forceps,  laryngeal,  in  position,  Fig.  70, 

320 

holder,  Cohen's,  pharyngeal,  Fig.  66, 
246 

Turnbull's,  Fig.  67,  246 
plug  in  hay  fever,  202 
wad  in  simple  chronic  rhinitis,  83 
wool  tampons  in  atrophic  rhinitis,  129 
Creosote,  therapeutic  properties  of,  59 
Croup,  spasmodic,  376 
Croupous  pharyngitis,  261 
Cubebs  in  chronic  posterior  nasal  pharyn- 
gitis, 229 

subacute  laryngitis,  329 
oil  of,  in  acute  rhinitis,  70 
atrophic  rhinitis,  120 
therapeutic  properties  of,  50 
oleo-resin  of,  in  atrophic  rhinitis,  265 

scrofulous  rhinitis,  135 
Curette,  bent  tip,  Fig.  59,  213 
Ciross',  Fig.  58,  212 
Volkmann's,  Fig.  42,  129 
disco's  laryngeal  forceps,  Fig.  88,  388 
Cutter,  Ephraim,  section  of  thyroid  carti- 
lage, 389 
Cynanche  tousillaris,  281 


428 


INDEX. 


Cysts  in  the  larynx.  381 
nasal  cavities,  150 

treatment  of,  150 
Czermak,  laryngoscopy  and  rhinoscopy,  1 

Daly  on  hay  fever,  171 

Dauzat,  treatment  of  maggots  in  the  nose, 

215 
Delavan,  Bryson,  on  causes  of  deviation  of 

the  septum,  1G1 

alimentation  bottle,  Fig.  81,  318 
in  cancer  of  the  larynx,  392 
m  tuberculous  pharyngitis,  267 
in  malignant  tumors  of  the  larynx, 

392 

Depression  of  the  epiglottis,  304 
Deviation  of  the  septum,  160 
etiology  of,  160 
pathology  of,  161 
symptoms  of,  162 
treatment  of,  163 
Diaphoresis  in  acute  laryngitis,  332 

rhinitis,  68 

Diseases  of  anterior  nasal  cavities,  64 
larynx,  327 

posterior  nasal  cavity,  216 
pharynx,  250 
septum,  160 
tonsils  and  uvula,  281 
Donaldson  on  treatment  of  hypertrophy  of 

the  tonsils,  289 
mucous  polypi,  139 

Douche,  nasal,  with   thermometer   attach- 
ment, Fig.  15,  33 
Dry  catarrh,  114 

pharyngitis,  263 

Ear  curette,  Gross',  212 

Ecchondromata  of  the  nasal  cavities,  150 

pathology  of,  151 

symptoms  of,  151 

treatment  of,  151 
Electric    illumination,   lamp    for,    Fig.    7, 

10 
Electricity,  9 

hysterical  aphonia,  375 

motor  paralysis  of  the  larynx,  372 

simple  chronic  rhinitis,  84 

paralysis  of  the  pharynx,  277 


Electrode,  Mackenzie's  laryngeal,  Fig.  82, 

372 
Electrolysis  in  fibrous  polypi,  148 

mucous  polypi,  146 

naso-pharyngeal  polypus,  237 

tumors  of  the  pharynx,  276 
Elliotson  on  hay  fever,  170 
Elongated  uvula,  295 

Elsberg's  ethereal  solution  of  iodoform,  347 
Epiglottis,  depression  of,  304 
Epistaxis,  etiology  of,  206 

pathology  of,  206 

prognosis  of,  207 

symptoms  of  207 

treatment  of,  208 

Ergotin  bougies  in  simple  chronic  rhinitis, 
82 

retro-pharyngeal  polypus.  238 
Erythematous  laryngitis,  327 
Escharotics  in  medication  of  nasal  cavities,  62 
Eucalyptus,  oil  of,  in  acute  rhinitis,  70 

atrophic  rhinitis,  120 

therapeutic  properties  of,  59 
Exostosis  of  nasal  cavities,  153. 

pathology  of,  153 

symptoms  of,  153 

treatment  of,  154 

saw,  Fig.  46,  154 
Extension  of  the  vocal  bands,  303 
Extirpation  of  the  larynx  in  semi-malignant 
tumors,  390 

malignant  tumors,  392 
Faradic  current  in  anosmia,  205 
Fauvel  on  cancer  of  the  larynx,  391 

treatment  of  atrophic  pharyngitis,  265 

laryngeal  forceps,  Fig.  87,  387 

modification  of  Mackenzie's  electrode, 

373 
Ferric  alum  in  relaxation  of  soft  palate  and 

uvula,  297 
Fetid  catarrh,  130 

coryza,  130 
Fibromata,  laryngeal,  381 

nasal,  146 
Fibrous  polypi,  nasal,  146 

pathology  of,  146 

prognosis  of,  147 

symptoms  of,  146 

treatment  of,  147 


INDEX. 


429 


Flat  and  crescentic  nasal  bougies,  Fig.  29, 

81 

Fluxus  nasalis,  71 
Follicular   disease  of  the  naso-pharyngeal 

space,  218 

Folliculous  pharyngitis,  255 
etiology  of,  255 
pathology  of,  256 
prognosis  of,  258 
symptoms  of,  257 
treatment  of,  258 
Foot-bath,  in  epistaxis,  208 

spasm  of  the  larynx,  377 
Foreign  bodies  in  nasal  cavities,  211 
symptoms  of,  211 
treatment  of,  212 
in  the  larynx,  393 
symptoms  of,  393 
treatment  of,  394 
in  the  pharynx,  277 
extraction  of,  279 
prognosis  of,  279 
symptoms  of,  278 
treatment  of,  279 

Fox's  head  band  and  reflector,  Fig.  2,  3 
Fraenkel  on  treatment  of  atrophic  rhinitis 

by  cautery,  119 
Freidrichshall  water  in  chronic  laryngitis, 

311 

Fumes  of  nitrated  blotting   paper  in  hay 
fever,  204 

Galvanism  in  atrophic  pharyngitis,  265 
Galvano-caustic  snare  in  removal  of  fibrous 

polypi,  147 

in  treatment  of  hay  fever,  192 
Galvano-cautery  battery,  author's,  98 
Seiler's,  97 
Piffard's,  97 
in  acute  rhinitis,  71 
atrophic  rhinitis,  119 
folliculous  pharyngitis,  259 
hypertrophic   posterior  nasal  pharyn- 
gitis, 232 

hypertrophic  rhinitis,  97,  109. 
hypertrophy  of  the  tonsils,  289 
laryngeal  tumors,  382 
nasal  mucous  polypi,  143 
simple  chronic  rhinitis,  79,  82 


Galvano-cautery     battery,     in     scrofulous 

rhinitis,  135 

tumors  of  the  pharynx,  275 
snare,  Allen's,  Fig.  37,  105. 
author's  in  position,  Fig.  40,  111 
Gallic  acid  in  epistaxis,  208 
Garcia  on  illumination  of  larynx,  1 
Glacial  acetic  acid  applicator,  author's  Fig. 

55,  196 

sol.  in  atrophic  rhinitis,  119 
hay  fever,  195 
hypertrophic  rhinitis,  96 
mucous  polypi,  143 
papillomata,  150 
therapeutic  properties  of,  62 
Glasgow,  of  St.  Louis,  vaseline  in  post-nasal 

catarrh,  228 
Glottis,  spasm  of,  376 
Goodwillie's  nostril  dilator  modified,  23 
Gottstein  on  treatment  of  atrophic  rhinitis, 

120 

Granular  pharyngitis,  255 
Gross,  S.  D.,  on  foreign  bodies  in  the  larynx, 

393 

ear  curette  for  the  extraction  of  for- 
eign  bodies   in    the    nose,    Fig.   58, 
212 
Guaiac  in  acute  pharyngitis,  252 

tonsillitis,  284 

Guye's  operation  for  the  removal  of  post- 
nasal  adenoid  growths,  234 

Hack  on  middle  sensitive  area  in  the  nose, 

181 
Hall,  Marshall,  pathology  of  spasm  of  the 

larynx,  376 
Hall's    syringe,    with    Cohen's    post-nasal 

tube,  Fig.  16,  37. 

Ilamamelis,  oil  of,  in  hay  fever,  203 
Hay  asthma,  170 
fever,  170 

curative  treatment  of,  19(3 
etiology  of,  170 
palliative  treatment  of,  201 
pathology  of,  185 
symptoms  of,  18!) 
Helmholtz  on  hay  fever,  17" 

on  treatment  of  hay  fever,  203 
Hemorrhagia  narium,  206 


430 


INDEX. 


Herpes  pharyngis,  261 

Hooper,  F.  II.,  on  iuiiervation  of  the  larynx, 

362 
on    action    of    thyro-cricoid    muscles, 

368 

Hunyadi  water  in  simple  chronic  pharyn- 
gitis, 251 
Hydrastis    canadensis    bougies    in    simple 

chronic  rhinitis,  82 
llydrated  chloride  of  calcium   in   chronic 

posterior  nasal  pharyngitis,  228 
Hydrochlorate  of  cocaine  (see  cocaine). 

therapeutic  properties  of,  58. 
morphia  in  acute  rhinitis,  69. 

simple  chronic  rhinitis,  77 
pilocarpine  in  acute  rhinitis,  69 

atrophic  pharyngitis,  265 
Hydrocyanic  acid,  therapeutic  properties  of, 

61 
Hygienic  measures  in  simple  chronic  rhinitis, 

79 

Hyoscyamus  infusions  in  tuberculous  phar- 
yngitis, 267 

therapeutic  properties  of,  61 
Hypera3sthetic  rhinitis,  periodical,  170 
Hypertrophic  nasal  catarrh,  85 
ozcena,  85 

posterior  nasal  pharyngitis,  229 
etiology  of,  229 
pathology  of,  230 
prognosis  of,  232 
symptoms  of,  230 
treatment  of,  232 
rhinitis,  85 

etiology  of,  85 
pathology  of,  85 
prognosis  of,  90 
symptoms  of,  86 
treatment  of,  91 

Hypertrophy  of  the  tonsils,  286 
astringents  in,  288 
etiology  of,  286 
pathology  of,  286 
prognosis  of,  288 
symptoms  of,  287 
treatment  of,  288 
of  the  turbinated  bones,  85 
Hypodermic  syringe  in  haematoma  of  the 
septum,  169 


Hypophosphites,  syrup  of,  in  chronic  poste- 
rior nasal  pharyngitis,  228 
scrofulous  rhinitis,  135 
Hysterical  aphonia,  37-4 
etiology  of,  374 
symptoms  of,  37-1 
treatment  of,  375 
paralysis  of  the  vocal  cords,  374 

Ice  bags  in  epistaxis,  208 

water,  salt,  in  epistaxis,  208 
Idiosyncratic  coryza,  170 
Illumination,  1 
Ingals,  Fletcher,  operation  for  deviation  of 

the  septum,  H>3 

Inhalations  in  acute  rhinitis,  70 
Inhaler,  steam,  Fig.  28,  50 
Instruments  used  in    cleansing  and  medi- 
cating the  nasal  cavities,  33 
larynx,  318 
pharynx,  244 
Insufflator,  nasal,  for  the  use  of  patients, 

Fig.  27,  48 
scoop,  Fig.  25,  46 
Smith's,  Fig.  26,  47 
Iodide  of  iron   in  chronic  posterior   nasal 

pharyngitis,  228 
potassium  in  hay  asthma,  203 
atrophic  pharyngitis,  265 
syphilitic  laryngitis,  354 

rhinitis,  127 

zinc,  in  simple  chronic  rhinitis,  77 
Iodine  in  acute  rhinitis,  70 
atrophic  pharyngitis,  265 
retro-pharyngeal  polypus,  238 
simple  chronic  rhinitis,  76 
therapeutic  properties  of,  58 
lodoform  in  syphilitic  laryngitis,  355 
syphilitic  rhinitis,  128 

pharyngitis,  271 
tuberculous  laryngitis,  347 

therapeutic  properties  of,  60 
Iron  in  chronic  posterior  nasal  pharyngitis, 
228 

epistaxis,  209 
hay  fever,  201 
scrofulous  rhinitis,  135 
chloride  of,  tincture  of,  in  mucous  polypi, 
139 


INDEX. 


431 


Iron,  chloride  of,  tincture  of,  in  syphilitic 
pharyngitis,  271 
tonsillitis,  285 

syrup  of   iodide  of,  in  scrofulous  rhi- 
nitis, 134 

chronic  posterior  nasal  pharyngi- 
tis, 228 

Jarvis,  of  New  York,  on  causes  of  deviation 

of  the  septum,  160 

combined  tongue  depressor  and  rhinos- 
cope,  108 
snare,  author's  modification  of,  Fig.  38, 

106 
transfixing  needles,  Fig.  35,  103 

in  nasal  fibroma,  149 
June  cold,  170 

Lamp  for  electric  illumination,  Fig.  7,  10 

oil  illumination,  Fig.  6,  7 
Laryngeal  aperture,  contraction  of,  305 
catarrh,  chronic,  336 
caustic  applicator,  MacCoy's,  Fig.  83, 

383 

cotton  forceps  in  position,  Fig.  79,  320 
electrode,  Mackenzie's,  Fig.  82,  372 
forceps,  Cusco's,  Fig.  88,  388 
Fauvel's,  Fig.  87,  387 
position   behind  soft  palate,  Fig. 
24,  44 

in  mouth,  Fig.  23,  43 
image,  313 
mirror,  Fig.  76,  310 

in  position,  Fig.  77,  312 
mucous  membrane,  306 
phthisis,  343 

Laryngismus  stridulus,  376 
Laryngitis,  acute,  330 
acute  catarrhal,  330 
catarrhal,  327 
chronic,  336 

catarrhal,  336 
erythematous,  327 
cedematous,  334 
simple  catarrhal,  327 
specific,  349 
subacute,  327 
syphilitic,  349 
tuberculous,  343 


Laryngoscopy,  310 

obstacles  to,  31") 
Laryngotomy,  398 
Laryngo-tracheotomy,  400 
Larynx,  300 

anatomy  of,  300 

artificial  openings  into,  398 

catarrh  of,  acute,  330 

instruments    used    in    cleansing     an  1 

medicating  the,  318 
neuroses  of,  357 
cedema  of,  334 
physiology  of,  308 
spasm  of,  376 
syphillis  of,  349 
therapeutics  of,  324 
Lead,  acetate  of,  in  chronic  posterior  nasal 

pharyngitis,  228 
in  epistaxis,  209 
syphilitic  pharyngitis,  271 
therapeutic  properties  of,  56 
Leeches  in  acute  laryngitis,  333 
Lentz's  atomizer,  Fig.  78,  318 
Levis  R.  J.,  treatment  of  epistaxis,  209 
Light,  albo-carbon,  6 
oxy -hydrogen,  8 
Lime   water   in   membranous   pharyngitis, 

262 

tonsillitis,  286 
therapeutic  properties  of,  53 
Lincoln,    on    treatment    of    nasal    polypi- 

148 

Listerine  in  atrophic  rhinitis,  121 
London    paste    in    folliculous  pharyngitis, 

260 

hypertrophy  of  the  tonsils,  2S9 
Longet  on  motor  paralysis  of  the  larynx, 

358 

Lowenberg,  of  Paris,  on  etiology  of  poste- 
rior nasal  pharyngitis,  229 
Lubrication  of  the  vocal  bands,  305 
Lugol's  sol.,  therapeutic,  properties  of,  60 
Lycopodium  as  a  protective,  02 

Mackenzie,   J.    N.,   reflex    cough    due    to 

polypi,  138 

on  etiology  of  hay  fever,  1 72 
on  posterior  sensitive  area  m  the  nose, 

181 


432 


INDEX. 


Mackenzie,    Morell,    on    the    etiology    of 

naso-pharyngeal  polypi,  235 
treatment  of    folliculous    pharyngitis, 
2(  »0 

hypertrophy  of  the  tonsils,  289 
bull-eye  condenser,  Fig.  4,  5 
laryngeal  electrode,  Fig.  82,  372 

forceps,  Fig.  86,  386 
nasal  bone  forceps,  Fig.  45,  ]  41 
tanno-gallic  acid  gargle,  2!' I 
valerianate  of  zinc  pill  for  hay  fever, 

201 

Maggots  in  the  nose,  214 
symptoms  of,  214 
treatment  of,  214 

Malignant  tumors  of  the  larynx,  390 
Mathieu's  tonsillotome,  Fig.  71,  290 
Mac  Coy  on  treatment  of  retro- pharyngeal 

abscess,  274 
laryngeal  caustic  applicator,  Fig.  83, 

383 
modification    of    Goodwillie's    nostril 

dilator,  22 

Medication  of  the  larynx,  325 
nasal  cavities,  54 

alteratives  in,  59 
astringents  in,  55 
escharotics  in,  62 
protective  in,  61 
sedatives  in,  60 
stimulants  in,  57 
Medicating  and  cleansing  of  nasal  cavities 

instruments  used  in,  33 
pharynx,  instruments  used  in,  244 
Membranous  pharyngitis,  261 
etiology  of,  261 
pathology  of,  261 
prognosis  of,  262 
symptoms  of,  261 
treatment  of,  262 
sore  throat,  261 

Mercurial  inunctions  in  syphilitic  laryngi- 
tis, 354 

Mercury,  acid  nitrate  of,  in  syphilitic  phar- 
yngitis, 271 

bichloride  of,  in  chronic  posterior  nasal 
pharyngitis,  228 

in  scrofulous  rhinitis,  135 
red  iodide  of,  in  syphilitic  rhinitis,  127 


Meyer   on   diagnosis   of   adenoid   growths 

of  naso-pharynx,  232 
Michel  on  treatment  of   deviation  of  the 

septum,  163 
Mitigated   stick    in   syphilitic  pharyngitis, 

271 

Moore  on  hay  fever,  170 
Morgan,   of    Washington,    on    etiology   of 

laryngeal  paralyses,  363 
Morphia  in  chronic  posterior  nasal  pharyn- 
gitis, 227 

malignant  tumors  of  the  larynx,  392 
sarcoma  of  the  nose,  158 
subacute  laryngitis,  330 
tuberculous  laryngitis,  347 
tuberculous  pharyngitis,  267 
hydrochlorate  of,  in  acute  rhinitis,  69 

in  simple  chronic  rhinitis,  77 
therapeutic  properties  of,  61 
Motor  paralysis  of  the  larynx,  357 
etiology  of,  357 
pathology  of,  357 
treatment  of,  371 

Mucous  membrane,  laryngeal,  306 
polypi,  nasal,  136 
etiology  of,  137 
pathology  of,  137 
prognosis  of,  139 
symptoms  of,  137 
treatment  of,  139 
Mustard  foot-bath  in  acute  laryngitis,  332 

spasm  of  the  larynx,  377 
plaster  in  epistaxis,  208 
Myxomata,  laryngeal,  381 

nasal,  136 

Nasal  cavities,  anterior,  12 
neuroses  of,  170 
medication  of,  54 
physiology  of,  19 
therapeutics  of,  52 
Nasal  cavity,  posterior,  17 
Nasal  catarrh,  acute,  64 
chronic,  71 
hypertrophic,  85 
cotton  carrier,  42 
bone  forceps,  Fig.  52,  168 

Mackenzie's  Fig.  45,  144 
douche,  directions  for  the  use  of,  34 
douche  in  scrofulous  rhinitis,  134 


INDEX. 


433 


Nasal  douche  with  thermometer  attachment, 

Fig.  15,  33 
insufflator,  for  the  use  of  patients,  Fig. 

27,  48 

passages,  foreign  bodies  in,  211 
plough,  Woakes',  in  position,  Fig.  41, 
113 

in  recurring  nasal  polypi,  145 
specula,  Allen's,  Fig.  34,  101 
Naso-pharyngeal  polypus,  234 
etiology  of,  234 
pathology  of,  235 
prognosis  of,  236 
symptoms  of,  235 
treatment  of,  236 
Nelaton's  operation  to  expose  posterior  nasal 

cavity,  237 
Nerve    stimulants    in    hysterial     aphonia, 

375 

Nervous  aphonia,  374 
Neuroses  of  anterior  nasal  cavities,  170 

the  larynx,  357 

Nitrate  of  silver  in  atrophic  rhinitis,  121 
chronic  laryngitis,  341 
chronic  posterior  nasal  pharyngitis,  260 
hypertrophy  of  the  tonsils,  289 
laryngeal  tumors,  382 
simple  chronic  pharyngitis,  255 
syphilitic  laryngitis,  353,  355 
pharyngitis,  271 
rhinitis,  127,  128 
tuberculous  laryngitis,  347 

pharyngitis,  267 
therapeutic  properties  of,  56,  58 
Nitrated  blotting  paper,  fumes  of,  in.  hay 

fever,  204 

Nitric  acid  in  hypertrophic  rhinitis,  95. 
papillomata,  150 
simple  chronic  rhinitis,  78 
therapeutic  properties  of,  62 
Nitrous  ether,  spirits  of,  in  hay  fever,  203 
Non-malignant  tumors  of  the  larynx,  378 
Nose-bleed,  206 

elevator,  Fig.  9,  23 
maggots  in,  214 
Nostril  dilator,  Bosworth's,  Fig.  8,  23 

modification  of  Goodwillie's,  Fig.  10,  23 
Nozzle  for  posterior  irrigation  in  position, 
Fig.  30,  94 


Nux  vomica  in  hay  fever,  201 
hysterical  aphonia,  375 

(Edema  glottidis,  334 
of  the  larynx,  334 
etiology  of,  334 
pathology  of,  335 
prognosis  of,  336 
symptoms  of,  335 
treatment  of,  336 
(Edematous  laryngitis,  334 
Ober's  improvement  of  Trousseau's  canula, 

.      404 

Obstacles  to  laryngoscopy,  315 
Oertel,  classification  of  papillomata,  380 
Oil  illumination  and  lamp,  Fig.  (5,  7 
Ollier's  operation  to  expose  nasal  cavities, 

148 
Opium  in  acute  pharyngitis,  252 

infusion  inhalations  in  tonsillitis,  285 

tuberculous  pharyngitis,  267 
tincture  of,  in  acute  rhinitis,  68 
Osteoma  of  the  nasal  cavities,  152 
pathology  of,  152 
symptoms  of,  152 
treatment  of,  153 

Oxide  of  zinc,  ointment  in  hay  fever,  202 
in  chronic  posterior  nasal  pharyngitis, 

227 

Oxy -hydrogen  light,  8 
Ozcena,  130 

hypertrophic,  85 
scrofulous,  130 
syphilitic,  122 

Palate  elevator  or  retractor,  Fig.  14,  30 
Papillomata,  laryngeal,  380 
of  the  nasal  cavities,  149 
pathology  of,  149 
symptoms  of,  149 
treatment,  149 
Paralyses  of  the  larynx,  357 
etiology  of,  357 
pathology  of,  357 
treatment  of,  371 
Paralysis  of  abduction,  364 

abduction,  adduction   and   relaxation, 

369 
adduction,  366 


434 


INDEX. 


Paralysis  of  tension,  368 
the  pharynx,  276 
etiology  of,  276 
symptoms  of,  277 
treatment  of,  277 
hysterical,  374 
Peach  cold,  170 

Periodical  hypersesthetic  rhinitis,  1 70 
etiology  of,  170 
pathology  of,  185 
symptoms,  of,  189 
treatment,  curative,  190 

palliative,  201 

Periosteal  knife,  Fig.  47,  155 
Permanganate   of   potassium    in    atrophic 

rhinitis,  118 
chronic  laryngitis,  340 
hypertrophic  rhinitis,  95 
membranous  pharyngitis,  263 
syphilitic  rhinitis,  128,  130 

pharyngitis,  271 
therapeutic  properties  of,  54 
Pharyngeal  applicator,  posterior,   Fig.  62, 

228 

atomizer,  Fig.  65,  245 
Pharyngitis,  acute,  250. 
atrophic,  263 
croupous,  261 
dry,  263 
follicular,  255 
granular,  255 
membranous,  261 
posterior  nasal,  acute,  216 
chronic,  218 
hypertrophic,  229 
sicca,  263 

simple  chronic,  253 
specific  chronic,  268 
syphilitic,  268 
tuberculous,  266 
Pharyngoscopy,  242 
Pharynx,  adenomata  of,  229 

anatomy  and  physiology  of,  239 
consumption  of,  266 
diseases  of,  250 
foreign  bodies  in,  277 
paralysis  of,  276 
syphilis  of  the,  268 
therapeutics  of,  248 


Pharynx,  tuberculosis  of,  266 

tumors  of,  275 

Phenol-sodique  in  atrophic  rhinitis,  119 
syphilitic  rhinitis,  128 
therapeutic  properties  of,  54 
Pilocarpine,  hydrochlorate  of,  in  acute  rhi- 
nitis, 69 

atrophic  pharyngitis,  265 
Phosphate  of  sodium  in  acute  pharyngitis, 

252 

folliculous  pharyngitis,  259 
Phosphorus  in  hay  fever,  201 
Phthisis,  laryngeal  343 
Physiology  of  the  nasal  cavities,  19 
larynx,  308 
pharynx,  241 

Piffard's  galvano-cautery  battery,  97 
Pine,  Canadian,  fl.  ext.  of,  in  simple  chronic 

rhinitis,  75 

oil  of,  therapeutic  properties  of,  59 
Pirrie  on  hay  fever,  160 
Plante's  storage  battery,  9 
Podophyllin  in  simple  chronic  pharyngitis, 

254 
Polypi,  fibrous,  nasal,  146 

mucous,  nasal,  136 
Polypus  forceps,  Fig.  43,  141 

in  removal  of  osteoma,  153 
naso-pharyngeal,  234 
snare,  Fig.  44,  142 

in  papillomata,  150 
Position  of  the  laryngeal  forceps  in  mouth, 

43 

behind  soft  palate,  44 
Position  of  patient  and  physician,  8 
Post-nasal  atomizer,  Fig.  60,  224 
catarrh,  218 

acute,  218 

cautery  loop  in  position,  Fig.  63,  233 
cutting  forceps,  Cohen's,  Fig.  64,  234 
Posterior  auto-insufflator,  Fig.  61,  226 

irrigation,  nozzle  for,  in  position,  Fig. 

30,94 

nasal  cavity,  diseases  of,  216 
pharyngitis,  acute,  216 

chronic,  218 

pharyngeal  applicator,  Fig.  62,  228 
rhinoscopic  image,  30 
rhinoscopy,  26 


INDEX. 


435 


Potassium,  bromide  of,  in  acute  rhinitis,  OS 
simple  chronic  rhinitis,  84 
therapeutic  properties  of,  54 
iodide  of,  in  atrophic  rhinitis,  265 
hay  asthma,  203 
syphilitic  laryngitis,  354 

rhinitis  127 
Potassium,   permanganate   of,   in   atrophic 

rhinitis,  118 
chronic  laryngitis,  339 
hypertrophic  rhinitis,  95 
membranous  pharyngitis,  263 
syphilitic  pharyngitis,  271 

rhinitis,  128,  130 
therapeutic  properties  of,  54 
Powder  insufflators,  46 
Probe,  Bosworth's,  Fig.  31,  96 
Protectives  in  medication  of  nasal  cavities, 

61 

Pruritic  rhinitis,  170 
Punches  and  blades  for  septum  forceps,  Fig. 

51,  167 
Purgatives  in  acute  rhinitis,  68 

in  folliculous  pharyngitis,  259 
Purulent  catarrh,  71 

Quinine  in  acute  rhinitis,  69 

chronic  posterior  nasal  pharyngitis,  228, 
229 

hay  fever,  201 

hysterical  aphonia,  375 

membranous  pharyngitis,  262 

scrofulous  rhinitis,  135 

spray  in  hay  fever,  203 
Quinsy,  281 

Rabuteau's  pills  of  carbonate  of  iron   in 

hysterical  aphonia,  375 
periodical  hyperaesthetic  rhinitis,  201 
syphilitic  laryngitis,  354 
Rag-weed  fever,  170 

Red  iodide  of  mercury  in  syphilitic  laryn- 
gitis, 354 
rhinitis,  127 
Reflector  with  circular  head  band,  Fig.  1,  2 

Fox's  head  band,  Fig.  2,  3 
Relaxation  of  soft  palate  and  uvula,  295 
etiology  of,  295 
pathology  of,  296 


Relaxation  of  soft  palate  and  uvula,  symp- 
toms of,  296 

treatment  of,  297 

the  vocal  cords,  304 
Relaxed  throat,  253 

and  uvula,  295 
Retro-nasal  catarrh,  218 

acute,  216 
Retro-pharyngeal  abscess,  272 

etiology  of,  '27'2 

prognosis  of,  274 

symptoms  of,  272 

treatment  of,  274 

trocar,  Fig.  68,  275 
Rhinitis,  acute,  64 

atrophic,  114 

hypertrophic,  85 

scrofulous,  130 

simple  chronic,  71 

specific,  122 

syphilitic,  122 
Rhinoliths  in  the  nose,  213 

etiology  of,  213 

symptoms  of,  213 

treatment  of,  214 
Rhinorrhagia,  206 
Rhinorrhoea,  acute,  64 

chronic,  71 

Rhinoscope,  Fig.  12,  27 
Rhinoscope  and  tongue  depressor  in  posi- 
tion, Fig.  13,  28 
Rhinoscopic  image,  anterior,  25 

posterior,  30 

view,  111 
Rhinoscopy,  anterior,  22 

posterior,  26 
Roberts,  J.  B.,  operation  in  deviation  of  the 

septum,  164 

Robinson,  Beverly,  carbolic  acid  locally  in 
hay  fever,  195 

on  treatment  of  nasal  mucous  polypi,  139 

ammoniacumin  post-nasal  pharyngitis, 

229 

Roe  on  hay  fever,  171 
Roger's  improvement  of  Trousseau's  canula, 

404 

Rose  cold,  170 

Rossbach's,  of  Wurzburg,  operation  for  the 
removal  of  laryngeal  tumors,  389 


436 


INDEX. 


Rouge's  operation  to  expose  nasal  cavities, 

148  ' 
Rumbold  on  nasal  irrigation,  40 

Salicylate   of  soda,   therapeutic   properties 

of,  54 

Saline  purgatives  in  acute  pharyngitis,  252 
Sarcoma  of  nasal  cavities,  157 
pathology  of,  157 
prognosis  of,  158 
symptoms  of,  158 
treatment  of,  158 
Sass'  spray  tubes,  Fig.  17,  38 
Saw,  exostosis,  author's,  Fig.  46,  154 
Scale  for  tracheotomy  tubes,  author's,  Fig. 

91,  405 
Scarification  in  acute  laryngitis,  333 

cedema  of  the  larynx,  336 
Scoop  insufflator,  Fig.  25,  46 
Scrofulous  ozoena,  130 
rhinitis,  130 

etiology  of,  130 
pathology  of,  131 
prognosis  of,  133 
symptoms  of,  131 
treatment  of,  134 
Section  of  nasal  cavities  illustrating  nervous 

distribution,  Fig.  53,  182 
Sedatives  in  medication  of  nasal  cavities, 

60 

simple  chronic  rhinitis,  84 
Seiler  treatment  of  chronic  laryngitis,  341 
galvano  cautery  battery,  97 
tube  forceps,  Fig.  69,  280 
Semi-malignant  tumors  of  the  larynx,  389 
Semon's  theory  as  to  comparative  proclivity 

of  abduction,  362 
on  abductor  paralysis,  365 
Septal  punch,  use  in  syphilitic  rhinitis,  129 
Septum,  abscess  of,  169 
deviation  of,  160 
diseases  of,  160 
forceps,  modification  of   Adams',  Fig. 

50,  166 

submucous  infiltration  of,  169 
Shurly  on  etiology  of  atrophic  pharyngitis, 

263 

on  treatment  of  atrophic  pharyngitis, 
265 


Simple  catarrhal  laryngitis,  327. 
chronic  pharyngitis,  253 
etiology  of,  253 
pathology  of,  253 
prognosis  of,  254 
symptoms  of,  253 
treatment  of,  254 
rhinitis,  71 

etiology  of,  71 
pathology  of,  72 
prognosis  of,  74 
symptoms  of,  72 
treatment  of,  75 

Smith,  Abbott,  on  hay  fever,  170. 
Smith's  powder  insufflator,  Fig.  26,  47 

treatment  of  laryngeal  affections,  322 
Snare,  Allen's  galvano-cautery,  Fig.  37,  105 
cold,   in   removal  of  naso-pharyngeai 

polypus,  237 

cold  wire,  in  removal  of  nasal  fibrous 
polypi,  147 

ecchondromata  of  nasal  cavities, 

152 
galvanic,  in  removal  of  naso-pharyn- 

geal  polypus,  237 

galvano-cautery,  in  position,  Fig.  40, 
111 

removal  of  ecchondromata  of  nasal 
cavities,  152 

nasal  fibrous  polypi,  147 
evulsion  of  cysts  of  nasal  cavities,  150 

tumors  of  the  pharynx,  276 
Jarvis',  author's  modification  of,  Fig. 

38,  106 

Snowden's  atomizer,  Fig.  19,  41 
Snuffles,  64 
Soft  palate,  240 

elevator,  author's,  Fig.  14,  30 
relaxation  of,  295 
Sore  throat,  acute,  250 
aphthous,  261 
chronic,  253 
clergyman's,  255 
membranous,  261 
speaker's,  255 
syphilitic,  268 
Spasm  of  the  glottis,  376 
larynx,  376 

etiology  of,  376 


INDEX. 


437 


Spasm  of  the  larynx,  pathology  of,  376 
symptoms  of,  376 
treatment  of,  377 
Spasmodic  croup,  376 
Specific  catarrh,  122 

chronic  pharyngitis,  268 
laryngitis,  349 
rhinitis,  122 

Spray  tubes,  Sass',  Fig.  17,  38 
Starch,  as  a  protective,  02 
Steam   atomizer,   modification   of,   Siegle's, 

Fig.  80,  323 
inhalation's  in  acute  laryngitis,  333 

simple  chronic  rhinitis,  84 
inhaler,  Fig.  28,  50 

Steel's  operation  for  deviation  of  the  sep- 
tum, 166 
Stimulants  in  medication  of  nasal  cavities, 

57 
Stoerk,  diagnosis  of  abscess  in   tonsillitis, 

283 
guillotine  and  tube   forceps,  Fig.   84, 

384 

Stramonium  cigarettes  in  hay  fever,  204 
Strumous  catarrh,  130 
Strychnia  in  anosmia,  205 

chronic  posterior  nasal  pharyngitis,  228 

hysterical  aphonia,  375 

motor  paralysis  of  the  larynx,  373 

paralysis  of  the  pharynx,  277 

scrofulous  rhinitis,  135 

sulphate  of,  in  simple  chronic  rhinitis, 

84 

Subacute  laryngitis,  327 
etiology  of,  327 
pathology  of,  327 
prognosis  of,  328 
symptoms  of,  328 
treatment  of,  329 

Submucous  infiltration  of  the  septum,  169 
Sulphate  of    copper  in   chronic    posterior 

nasal  pharyngitis,  228. 
laryngitis,  341 
epistaxis,  209 

simple  chronic  pharyngitis,  255 
therapeutic  properties  of,  56 
strychnia  in  simple  chronic  rhinitis,  84 
zinc  in  chronic  posterior  nasal  pharyn- 
gitis, 228 


Sulphate  of  zinc  in  relaxation  of  soft  palate 

and  uvula,  297 
syphilitic  pharyngitis,  271 
tuberculous  laryngitis,  347 
spray  in  acute  laryngitis,  333 
therapeutic  properties  of,  56 
Sulpho-carbolate  of  zinc  in  acute  posterior 

nasal  pharyngitis,  218 
simple  chronic  rhinitis,  77 
Summer  catarrh,  170 
Surgical  engine,  Bonwill's,  Fig.  48,  156 

burrs,  Fig.  49,  157 
Swift's  cotton  and  bougie  carrier,  Fig.  21, 

42 

Symptoms  of  hay  fever,  189 
Syphilis  of  the  larynx,  349 

pharynx,  268 
Syringe,    Hall's,    with   Cohen's  post-nasal 

tube,  Fig.  16,  37 
Syphilitic  laryngitis,  349 
etiology  of,  349 
pathology  of,  349 
prognosis  of,  353 
symptoms  of,  850 
treatment  of,  353 
ozcena,  122 
pharyngitis,  268 
etiology  of,  268 
pathology  of,  268 
prognosis  of,  270 
symptoms  of,  268 
treatment  of,  270 
rhinitis,  122 

etiology  of,  122 
pathology  of,  122 
prognosis  of,  126 
symptoms  of,  123 
treatment  of,  126 

Systemic  treatment  in  hypertrophy  of  the 
tonsils,  295 

Talc.,  pulv.,  as  a  protective,  62 

Tampons,  cotton  wool,  in  atrophic  rhinitis, 

120 

Tannic  acid  in  chronic  posterior  nasal  phar- 
yngitis, 227 
epistaxis,  208 
simple  chronic  rhinitis,  76 
therapeutic  properties  of,  57 


INDEX. 


Tannin  in  hypertrophy  of  the  tonsils,  289 
mucous  polypi,  139 

relaxation  of  soft  palate  and  uvula,  297 
syphilitic  pharyngitis,  271 
tuberculous  laryngitis,  347 
Tanno-gallic  acid  gargle  in  amputation  of 

tonsils,  294 

Tar,  oil  of,  in  acute  rhinitis,  70 
atrophic  rhinitis,  120 
inhalations  in  hay  fever,  203 
therapeutic  properties  of,  59 
Therapeutics  of  nasal  cavities,  52 
larynx,  324 
pharynx,  248 
Throat,  chronic  catarrh  of,  253 

consumption  of,  343 
Thyrotomy,  399 

in  semi-malignant  tumors  of  the  larynx, 

390 
Tobold's  illuminator,  as  modified  by  Cohen, 

4 
Tongue  depressor.  Fig.  11,  26 

and    rhinoscope   in  position,  Fig.   13, 

28 

Tonsil  bistoury,  Fig.  70,  289 
Tonsils,  the,  241 

amputation  of,  289 
diseases  of,  281 
hypertrophy  of,  286 
Tonsillitis,  281 

etiology  of,  281 
pathology  of,  281 
prognosis  of,  283 
symptoms  of,  282 
treatment  of,  284 
Tonsillotome,  author's,  Figs.  72,  73,  and  74, 

292 

Mathieu's,  Fig.  71,  290 
Trousseau's  treatment  of  scrofulous  rhinitis, 

135 

dilator,  Fig.  89,  402 
tracheotomy  tube,  improved,  Fig.  90, 

404 

Tuberculosis  of  the  pharynx,  266 
Tuberculous  pharyngitis,  266 
etiology  of,  266 
prognosis  of,  267 
symptoms  of,  266 
treatment  of,  267 


Tuberculous  laryngitis,  343 
etiology  of,  343 
pathology  of,  343 
prognosis  of,  346 
symptoms  of,  344 
treatment  of,  346 
Tumors  of  the  larynx,  378 
malignant,  390 

symptoms  of,  391 
treatment  of,  392 
non-malignant,  378 
etiology  of,  378 
symptoms  of,  379 
treatment  of,  382 
pharynx,  275 

symptoms  of,  276 
treatment  of,  276 
semi-malignant,  389 
Turbinated  bones,  hypertrophy  of,  85 
Turnbull's  cotton  holder,  Fig.  67,  246 
Trachea,  artificial  openings  into,  398 
Tracheotomy,  400 

after  treatment  of,  405 

acute  laryngitis,  334 

foreign  bodies  in  the  pharynx,  280 

malignant    tumors     of     the     larynx, 

392 

oedema  of  larynx,  336 
removal  of  foreign  bodies  in  the  larynx, 

396 

spasm  of  the  larynx,  377 
tuberculous  laryngitis,  349 
tube  with  inner  canula  drawn  out,  Fig. 
92,  406 

Universal  handle,  author's,  Fig.  33,  99 

and    laryngeal    attachment,    author's, 

Fig.  85,  385 

Uvula,  amputation  of,  297 
diseases  of,  281 
elongated,  295 
relaxation  of,  295 
Uvulatome,  author's,  Fig.  75,  297 
Valerianate  of  ammonia  in  hay  fever,  203 

hysterical  aphonia,  375 
zinc  in  hay  fever,  201 

hysterical  aphonia,  375 
Vaseline  in  chronic  posterior  nasal  phar- 
yngitis, 228 


INDEX. 


439 


Vaseline  in  hay  fever,  202 

simple  chronic  pharyngitis,  255 
Vocal  bands,  abduction  of,  302 

adduction  of,  302 

extension  of,  303 

lubrication  of,  305 

relaxation  of,  304 
Volkmann's  curette,  Fig.  42,  129 

Warm  bath  in  spasm  of  the  larynx,  377 
\Voakes'  nasal  plough  in  position,  Fig.  41, 

113 
recurring  nasal  polypi  145 

Ziemssen's  modification  of  Mackenzie's  elec- 
trode, 373 
Zinc,   chloride    of,   in    chronic    laryngitis, 

342 

chronic    posterior    nasal    pharyngitis, 
228 


Zinc,  chloride  of,  in  chronic  posterior  nasal 
pharyngitis,  therapeutic  properties 
of,  56 

iodide  of,  in  simple  chronic  rhinitis,  77 
oxide   of,   in   chronic    posterior   nasal 

pharyngitis,  227 

oxide  of,  ointment,  in  hay  fever,  202 
in  chronic   posterior   nasal    phar- 

ynitis,  227 

sulphate  of,  in  relaxation  of  soft  palate 
and  uvula,  297 
syphilitic  pharyngitis,  271 
tuberculous  laryngitis,  347 
spray  in  acute  laryngitis,  333 

therapeutic  properties  of,  5(5 
sulpho-carbolate  of,  in  acute  posterior 
nasal  pharyngitis,  218 

simple  chronic  rhinitis,  77 
valerianate  of,  in  hay  fever,  201 
hysterical  aphonia,  375 


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WM.  WHITLA,  M.D.  (Q.  U.  I.) 

Physician  to  the  Belfast  Royal  Hospital,  Consultinff  Physician  to  the 
Ulster  Hospital  for  Women  and  Children,  Vice- President  of  the 
Ulster  Medical  Society,  Author  of  '•'•Manual  of  Pharmacy,  Materia 
Medica  and  Therapeutics"  Third  Edition. 


PHYSIOLOGICAL  CHARTS  OF  LIFE. 


r~pHE  need  has  Ions  been  felt  for  agood  Chart  of  Physiology— something  that  would,  in  a  convenient 
form,  show  the  full  outlines  of  the  subject  without  compelling  one  to  read  over  numberless  pages 
to  clear  up  some  point  that  could  be  seen  at  a  glance  if  on  a  proper  chart. 

I  Until  the  present,  nothing  of 
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SHOWING    THE    ENTIRK    PLAN 

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i  ions  of  the  Human  Body  and  its  Principal  Diseases. 

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THE  MEDICAL  BULLETIN 

A    MONTHLY   JOURNAL 


MEDICINE  it  SURGERY, 


EDITKD    BY 


JOHN  V,  SHOEMAKER,  A.M.,  M.D., 

Lecturer  on  Dermatology  in  Jefferson  Medical  College ;  Physician  in  charge  of  Philadelphia  Hospital  for 

Skin  Diseases;  Member  of  the  American  Medical  Association,  the  American  Academy 

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m&  jjest  ^fdical  jfonrmljor  they  rice  jtubU 

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HAY    FEVER 


AND  ITS  SUCCESSFUL  TREATMENT  BY  SUPER- 
FICIAL ORGANIC  ALTERATION  OF  THE 
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BY 


CHARLES    E.   SAJOUS,   M.D., 

Lecturer  on  Rhinology  and   Laryngology  in  the  Spring  Course  of  Jefferson  Medical  College;   one  of  the 


of  the 
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BOUND   IN   CLOTH,   FLEXIBLE    COVEK.      PKICE,   ONE   DOLLAK. 


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mid.  treatment  are  carefully  described,  and  the  latter  is  so  arranged  as 
to  be  practicable  by  any  physician. 


PUBLISHED  BY  F.  A.  DAVIS,  ATT% 
No.  1217  FILBEKT  STREET, 

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